Supervision

One of the weaknesses of my field placement has been the lack of supervision when I facilitate groups.  Altough I speak with my supervisor and other staff about what occurred in the group, they do not directly supervise my work and my conversations with them center around client issues, not my own.  Because of this situation, I entreat clients to provide honest feedback for groups.  I feel that since I try to present as a non-confrontational, accepting staff member, clients are more likely to be comfortable providing feedback to me.  

Sadly, the only feedback I've received has been positive.  I realize that sentence is paradoxical, but only through evaluating my mistakes can I grow as a clinician.  To compensate for the lack of negative feedback, I have, according to my field supervisor (not attached to the agency), developed a greater sense of self-awareness in practice which has grown through the year.  I relished this feedback.  

The group I led today was on Step One.  First, I had the clients apply the reading to their own experience, prompting them with a general query, "does anyone have anything to share about thre reading."  While sharing, a client broke down in tears because he identified greatly with the material in the reading regarding unmanagability of his life.  I brough his awareness to the present and validated him for sharing with the group.  After everyone had shared, I built off of a client's comments and posed the open question to the group, "What are some positive coping mechanisms you have used?"  The clients all started speaking at once, which I stopped to regain decorum.  Once some clients had shared, I asked a more difficult question on how to choose between positive and negative coping strategies and emphasized that just knowing that there is a choice is an important step.  

The reason I mention supervision is the feedback I received after closing my group today on Step One.  The clients made it a point to thank me for running a great group, which I found difficult to handle.  I simply replied that they did all of the talking, I just asked a few questions.  Also, the monitor present in the client room was so impressed she called down to my task supervisor to inform her of what a great job I did with the group.  This positive feedback bolsters my self-efficacy and makes me more secure in asking questions or making observations in the group.

Irony

One of the best experiences I have had at Samaritan Inns occurred last week. I was facilitating a group on "criminal or addictive thinking" with a focus on aggressive coping mechanisms. During this group, because my life is sublimely ironic, a heated argument erupted between two clients who had exchanged words before the group had started (unbeknown to me).

One of the most useful techniques and formulations I had learned in my social work placements was Life Space Interviews. When I was working with emotionally disordered children, life space interviews were employed after a crisis to process the events and highlight areas where the client could have chosen differently. Once I had calmed both of the parties in the argument down, I was able to chain the behaviors they were expressing on the whiteboard in the group. I could tell that the clients were building insight because they were able to identify their own behaviors in the chain. Also, they were able to suggest alternative behaviors.

After the behaviors were chained, they were able to speak to each other about the root of the problem. One client thought the other had overheard her speaking about her HIV status (not true). Later, that same client confronted the other about "her disease"-- referring to the disease of addiction-- and the other client thought she was talking about HIV. Independent of my own prompting, the clients were able to use "I" statements to express their feelings and found the truth at the center of the conflict.

Once the clients had expressed themselves in a more positive manner, I validated them for their effort to resolve the conflict. Then, in a writing assignment, I asked all members of the group to identify their aggressive strategies. Although I did not get to see the two clients' responses, I hope that they gained insight from their actions; especially, what they gained from these techniques and how they could have addressed the situation differently.

Cultural Issues

In a recent group lead by my supervisor, she touched on a topic that I had not considered during my time here. Although I was aware of a cultural gap between myself and the client group, I did not realize the cultural differences significantly affected my role with the clients. My supervisor spoke about how the client population might not be comfortable speaking about their problems with a therapist or counselor as a result of cultural teachings. Therapy and psychology were not the domain of African-Americans and mental health issues were regarded as a shameful process.

I began to think about why this had never dawned on me before. Then I realized how normal it was for me to constantly hear the problems and concerns of others. I have been working in a therapeutic setting for the past 2 years with little breaks in between jobs and settings. Even in my personal relationships, I often take on a supportive role like a counselor. I had become so acclimated to people (friends, family, clients) telling me about their problems that I was unable to fathom people having trouble divulging that sort of information. In addition, given my education in Psychology, I found it striking and strange that anyone would have trouble expressing their feelings because of cultural conditions (instead of personal trauma, which makes more sense to me).

I think I need to take a step back and take the perspective of the client again.

Confidentiality Issues

Last week, I was about to conduct a psychosocial assessment with one of the clients, when he asked me about confidentiality issues. Previously, I had asked my task supervisor for more information on who would see the assessments once they are completed. She responded that if I am asked anything, just to say that I have to do the assessment. I was unsatisfied with this answer, so I asked my MSW supervisor what I should do without that information. He suggested I speak to the client about the HIPPA laws and go over ethical issues around confidentiality.

In the situation, the client was worried about who would be reading this assessment. Without a clear policy in the institution, it is difficult to ascertain who will be able to access the information. Prior to the closing of the transitions program, where most clients would go, the assessments stayed within the Samaritan Inns organization. Clients are currently placed in external programs for the transitional phase, and arrangements are sometimes made without client input. As a result, it is unclear who will be receiving this assessment. In addition, given the lax computer security, the records themselves are not very secure. (There are password protections for the computers and the records program, but both the username and password for staff members is their first name and last name. I log on under other people's usernames daily because I don't have one.)

The client vacillated between concern and compliance as he was asking these questions. The environment here does not lend itself to this type of concern. I validated his concern, spoke on confidentiality rules for me as a social worker, and discussed his rights under HIPPA. I told him that he had complete control of who saw his records. However, I was unable to tell him the answer to whether background checks or the government could access it. Provisionally, he decided to complete the assessment and not answer any questions he feels inappropriate. Luckily, the assessment did not contain any sensitive topic areas.

Family

I have been fascinated by family therapy ever since I was introduced to Structural Family Therapy during my abnormal psychology class. In my first major field placement, I attended a seminar about family therapy. This session included theorists like Minuchin, but what interested me the most was Murray Bowen and the importance placed on the family unit in his theory. His insight really cemented within me the idea that family dynamics are represented directly within the individual and in their everyday lives. Combining that insight with the reading on Caribbean child-rearing beliefs, I see more clearly the cultural and familial differences that lead certain clients and clinicians to have divergent beliefs and strategies.  

One of the most important connections I have made out of this link is how the un-therapeutic practice of my fellow clinicians at Samaritan Inns mirrors poor family dynamics.  I believe that substance abuse is a maladaptive coping mechanism for psychological stress.  In addition, much of the psychological stress my clients (and some fellow clinicians) carry stems from their family relationships.  These unhealthy relationships are continually repropagated in daily interactions.  For example, when rules are not applied to certain individuals, are not applied consistently over time, and negative group roles are reinforced by staff, unhealthy family relationships are finding new expression in a different group context.  This process is grossly unhealthy for all involved.  The clients suffer greatly as their psychological needs of consistency, positive regard, and basic safety are neglected.

Questions

This week's reading about Questions was quite thought provoking and related greatly to the bulk of my work at Samaritan Inns.  One of my responsibilities at the organization is to complete the assessment paperwork with the client.  Although there is a form, there are no given questions--simply topic areas and answer spaces.  I have found that open-ended, but specific questions are the most effective at eliciting the information necessary to complete the form.  

In the Questions reading, the idea that people structure experience in a narrative fashion was particularly salient to my assessment work.  Hypothetically, take two clients with a similar substance abuse, treatment, medical, and psych history and ask them the same group of questions.  Their answers will vary in how detailed the narratives are and how much context they feel is necessary for the response.  For some clients, they are simply unaccustomed to filling out paperwork on their own lives and have a more conversational style.  Others, contrastingly, give rigid, factual responses with little embellishment.  In my experience, the client's personal history, especially prison time and psychiatric diagnosis, impacts their answering style.  Those who have been institutionalized provide simple answers, as they are accustomed to doing.  Those with psychiatric diagnoses will often provide more context for their responses, as often times these events are symptomatic of and/or contributory to their illness.  

The degree to which a client provides a detailed, narrative story is also emblematic of their emotional connection with the answer.  Some clients may feel ashamed or bitter about their legal history.  That emotional content necessitates a desire to have the clinician understand and validate those feelings.  These are often the most complicated answers.

Speaking to another point in the Questions article, the disparity in power between client and clinician often impacts the question-answer dialectic.  Last week, I had a client ask me, when prompted about his family, why I needed to know this information.  Often times, clients at my placements are chided for their presumptuousness.  However, his question was entirely valid, and I responded that it helped us to get a sense of his support network for his recovery.  From his reaction, I gathered that this response made sense to him and the rest of the assessment continued unabated.  

Finally, although this does not relate to my field placement, I actually used a "circular question" with a visiting friend who is undergoing psychiatric treatment.  We were speaking idly in the car while driving to my house, and I spoke of how "what others envy in us" is an interesting question.  Breaking the back-and-forth, he remarked that he had never thought about that before.  Since we're on an equal playing field, as opposed to a client-clinician relationship, we both sat back and pondered it for a moment--exploring that idea privately.

The Self

When clients arrive at Samaritan Inns, they are often in a period of intense uncertainty.  They are internally motivated towards personal change, but do not know what areas need to change.  Obviously, cessation of drug abuse is the primary concern; however, once achieving sobriety, most clients realize that the drugs were masking personal pain.  

More and more, I am feeling that my role within the group is to clarify the issues they bring up in groups.  For instance, a client was working to overcome issues dealing with family members and loved ones who continue to use drugs.  However, in her presentation of these issues she connected them with her lack of self-esteem and social anxiety.  

Although the two problems she interrelated, they were two distinct problems.  From the way in which she related her stress, the two distinct issues were tangled up with emotion.  My job in the interaction was to separate the two issues and suggest she tackle them independently.  In this sense, the communication went beyond empathy, into goal formation and personal change.