I didn't see that coming!!

It seems always challenging to be with our patients when they are dealing with something that we don't understand or haven't experienced it. To make it work, and it often does, takes patience, empathy and a person who is willing to teach us about their experiences.

On the other hand, having someone dealing with something that we know all to well can be disarming. This is when good supervision is really helpful, so we can tell the difference between our person reactions to our past experiences and are relations to this particular patent's experience.

Sometimes, we get to visit some of the more painful experiences. This happened recently when a patient return after many months. We had been working on helping her get through a awful accident. When I saw her name in my schedule, I thought that this was troubling her again. Instead, she was dealing with an abrupt break up with her boyfriend. As we discussed it, I was jolted back in my memory to a painful break up over 3 decades ago!! I was able to use what I learned from that experience to help her. When I saw my supervisor (fortunately in the next hour) I talked about how unprepared I was for that lovely memory.

In one of my first classes in social work school, the professor said,

" It is hard to take patients to places that you have not been."

Wise words.

portable quote

This quote came from Jim Garland , former group guru and faculty at the Boston University School of Social Work. Many years ago, I had organized a meeting with him an my fellow male social work students to talk about our experiences. He said,

Men have side by side relationships and women have face to face relationships.



For a sweeping generalization, I have found this to be very helpful over the years in understanding some important relational differences. I was reminded of it recently while meeting with a mother and her adult daughter. And it turned out that one of their struggles is that the daughter prefers a "face to face" relational approach while the mother prefers to have an activity involved approach, like cooking - a side by side approach. Being able to understand what they want from each other has meant and will continue to mean looking for intersecting relational opportunities.

family meals - analog for responses in group psychotherapy?

I'm way over due for submitting a new posting - it has been very busy with lots to figure out which made it feel hard to write. However, in my psychotherapy group last night there was a synergy in the topic that reminded me of something I was told years ago - and it finally made sense.

So, in group we revisited a frequently visited topic of the dynamics in their families of origin. We started with another frequent topic - the relationship of feelings and food. But last night they came together in an interesting way. We talked about how food and those early relationships were handled together. Specifically, what happened at the dinner table. Who did the cooking, what was talked about (if there was talking), what were the overt/covert messages one "consumed"? Very rich stuff. What I remembered was a from a former supervisor who told me that when she screened people for group , she also asked about their family's dinner times as this gave her a sens of how this person might handle themselves/react in a group.

So, the next step in group is to tie their interactions together in group to these earlier patterns. Can't wait to see what's cooking.

a bottle of wine and twin lobsters

Here we have been going through lay offs and significant cuts in benefits here and as can be expected, the anxiety level is high. I've been thinking a lot about self-care, but not always putting it into practice. As I thought about this, I just now remembered a conversation I had with a supervisor of mine when I trained at a Veteran's Administrations outpatient clinic. He was kind enough to let me co-lead a group for World War II former POW's. As this was during a previous economic recession, stress was high there as well. He and I talked about the stressful work and the stressful work environment. I asked him how he took care of himself. He said, "With a bottle of wine and twin lobsters." He and his wife (also a social worker) looked forward to their favorite restaurant's Friday Twin Lobster Special. It helped to create a closure for the week.

I have asked this question to many of my colleagues over the years and often think that there must be some secret to managing the stress that no one has taught me to do yet. Their answers are invariably around doing the things that give them pleasure (yoga, gardening, music). Is it that simple? Maybe its also having an evocative memory of good advice that helps!

"I'm optimistic"

Today, I heard Dr. Thomas Graboys talk about his living with Parkinson's disease. Despite the losses he has suffered, he expressed a number of times how he feels optimistic. Here is the review in the New York Times of his book. Check it out - his optimism is as contagious as is his courage.

I would like a new perspective

Mustafa: [taking Ego's order] Do you know what you'd like this evening, sir?

Anton Ego: Yes, I think I do. After reading a lot of overheated puffery about your new cook, you know what I'm craving? A little perspective. That's it. I'd like some fresh, clear, well seasoned perspective. Can you suggest a good wine to go with that?

You may recognize the above dialogue from the movie Ratatouille. The dreaded food critic, Anton Ego has come to Gusteau's to review the work of the new chief and he asks for new perspective and gets it!

Since seeing this movie, when I am feeling baffled by a clinical situation or just plain stuck, I now ask my supervisors for "a new perspective". What they have to say is not always so easy for me to take in or even to understand. Their advice challenges my defenses (read "EGO") : "I should know this." "After all of these years why didn't I see this?" "What I have been doing couldn't be wrong?". It forces me to see dynamic and complex issues in a different way. And when I see my patient for our next session, I more often than not have a clearer sense of how to approach what we have been working on. And like Anton Ego, I'm surprised by what I find.

the wrong use of authority

This week the Pope, on his way to Cameroon, told people that the Catholic Church does not endorse the use of condoms to decrease transmission rates of HIV, in fact he thinks that it makes the problem worse! It is shocking to think that the leader of the largest Christian denomination (over 2 billion members and growing) selectively comments on critical public health issues. There is a body of evidence that shows that the use of latex condoms "substantially reduces the risk for HIV transmission". It also is effective for other sexually transmitted diseases, like HPV.

I thought that I would let the Pope know that I think he should reconsider his position. He supposedly has an email account: benedictxvi@vatican.va. Here's what I wrote:

Dear Holy Father, I’m sure that you will be hearing from others who know about the science behind barrier protection in decreasing the incidence of HIV transmission. I wish that you and your advisers would please consider that your advocating for not using condoms is harmful. It is not informed by sound epidemiological studies. Advocating for condom use does not lead to more casual sexual encounters. Please leave your dogma behind and use your authority to speak to the pressing needs of those who still want to listen to what you have to say.

Maybe you would like to write him as well. I'll post any response that I get back from the Vatican.


3/24 update

Here is my answer:


This is the mail system at host lists.vatican.va.
I'm sorry to have to inform you that your message could not be delivered to one or more recipients. It's attached below.
For further assistance, please send mail to postmaster.
If you do so, please include this problem report. You can delete your own text from the attached returned message.
The mail system
: host 212.77.0.211[212.77.0.211] said: 452 4.2.1
mailbox temporarily disabled: benedictxvi@vatican.va (in reply to RCPT TO
command)

So the mailbox has been "temporarily disabled". This has me thinking about the process of giving feedback. Here in the US, if we disagree with our federally elected leaders, we can go to our representatives in Congress and ask for their input. Granted this tends to be a futile effort, but we can exercises our discontent when voting comes around. To whom do we discuss our dissatisfaction with the Vatican, our local priest? I guess that is why these struggles get exercised in the press and in public opinion.

There is a connection to psychotherapy. There are a number of my current patients who are finding their "voice" and speaking up for themselves in current struggles and past abuses. They have needed to overcome their fears of retribution, relearn trust and still maintain some wariness (appropriately so) of those who have authority. The Vatican's handling important issues with blunt instruments may cause more damage than the obvious increase in sexually transmitted diseases.

bearing suffering and bearing witness

At our Grand Rounds this week, Jodie Wigren MSW, Ph.D. from the Trauma Center talked about the intersection of psychodynamic and trauma theory in working with survivors of trauma. She summarized in a beautiful way the interesting phase shift in this work:

First patients learn to bear suffering and then learn to bear witness.

In and earlier posting, I wrote about the other side of this dynamic, the therapist's learning to sit with the affect (feelings, suffering) in order to share in the bearing witness. I going to add this quote to my repertoire.

the absence of a postive

In recent years, I came across this statement in an clinical study on happiness (I've since lost the reference - if you know it please pass it along):

The absence of a positive is more strongly felt than the presence of a negative.

I found myself saying this to a group I consult to as they were discussing the changes they anticipate with this most recent round of funding cuts. They (and the rest of us) are facing or will soon face not having something or the access to something that we had grown to count on as essential in our being able to do our work in a sustaining manner. That loss will be felt and cause anxiety - look at discussions about the prospects of cutting entitlements! However, when we learn to live with things that we experience as negatives, we adapt and accept.

Is there something to learn from this? One of the challenges of losing the things we have come to count on will dealing with how we feel about it. We need to maintain our perspective. Maybe we also need to look at those things that we think of as negatives and ask if there is something we can do about them.

It takes a village to treat a patient

I borrow this borrowed phrase to try to capture the concept behind a role of a group consultation. For over a decade, I am privileged to be in a supervision group with a gifted supervisor and trusted colleagues where we have been working together to become better clinicians and to get sage advice on how to proceed with very challenging patient situations. These are the typical and essential roles of a good supervision. However, in recent years we have come to appreciate a different type of role our group can serve. We have brought some of our patients to our group supervision for a consultation with the group, but also to create a broader support for the clinician and the patients. We’ve noticed that these patients feel more understood and better supported because “the group” is there encouraging them on to do the hard work and that their therapist has “the group” for support and guidance. Over the past year it has helped a couple of my patients to integrate an important element of self-care by knowing that there was “a village” looking out for them.