Much of my everyday clinical social work could be highlighted
by three idioms of the English language:
Meet me halfway
A fighting chance
Have a nice day
Let's get started
with some impressions of the first idiom. Treating mandated
patients can sometimes be a trying experience even for the most
dedicated therapist. Some mandated patients present with severe
anger and hostility. Referrals from the criminal justice system,
for example, can require the therapist to set firm behavioral
limits in order for the therapeutic work to proceed. Learning
the skill of meaningful and tactful confrontation can seem foreign
to therapists unaccustomed to the mandated population.
will develop their own style in establishing a trusting
relationship with their patients. I will share with you a simple
yet effective way that works for me when treating resistant
patients. I just ask them to meet me halfway. It is usually
evident from the first session if I must engage an unmotivated
individual who feels, real or perceived, that the legal system
has treated him unfairly.
For this type of
patient, mere cooperation with the treatment mandate is a
significant accomplishment. These patients are struggling to
accept responsibility for self, for their behavior, and for the
consequences of their behavior. They need to learn there is a
connection between their actions and the trouble they get into.
By meeting the
therapist halfway, the patient agrees to keep his counselling
appointments, fulfill the treatment plan, and to keep an open
mind. His incentive to cooperate with treatment is reinforced,
that incentive being to avoid an unwanted alternative such as jail
or to obtain a positive reward such as getting his driver's
If the patient can
keep an open mind he will possibly learn new coping skills and
gain insight into his non-productive behaviors and attitudes.
This type of patient usually seems to understand that the
therapist has a job to do, and appreciates a
straight-forward approach. The therapist's respect for a
difficult patient can in itself gain a lot of therapeutic mileage.
Some of these patients will internalize the treatment mandate into
their own desire for a better life.
By meeting the
patient halfway, the therapist enables the the patient to have as
much self-determination as possible in a court-mandated situation.
The patient is engaged in a therapeutic situation in which he can
gain recognition that his loss of self-determination to the courts
was due to his socially unacceptable behavior. This behavior, in
turn, is often due to an addictive disorder. The patient can then
exercise self-determination by making an informed decision for
himself whether to continue or to change these harmful behaviors.*
For the mandated
population, a trusting relationship with the therapist is
crucial. The therapist must be genuine and believable, otherwise
the street-smart patient will see through any insincerity.
Let's move on to the
second idiom. There are some patients who just need a fighting
chance to survive in this world. It is as though they live in a
mental fog. They seem to need the therapist to clarify reality,
validate their feelings, help them to stop repeating dysfunctional
relationships and situations, and offer them suggestions for
change. There are certain sensitive, vulnerable people who need,
so to speak, to wise up and toughen up.
I remember a French
language teacher that I had when I was in school. He was having
difficulty teaching French because some of the students had never
learned English grammar. They were in a fog. They did not know
the difference between an adjective and an adverb, a direct object
and an indirect object, and so on. This teacher loved teaching and
he really wanted the class to learn and enjoy French. Therefore,
he spent a portion of each class hour teaching English grammar so
that the students would have a fighting chance to speak
Having a fighting
chance means that someone has cared enough to equip you with the
essentials, and then the rest is up to you. Perhaps others failed
you in the past and, as a result, you became emotionally crippled
in some way. But now someone, a competent therapist, has helped
you to grow. Now it is under your control, within your power, to
make something good happen for yourself.
This is in keeping
with a basic social casework principle: that not only are people
acted upon by the environment, but that they can also act upon
their environment. Some patients have been acted upon so
negatively that they need someone to help sort out the dynamics,
validate the impact, and support them in becoming successful and
influential participants in their environment.
Finally, I have come
across some patients who just seem to need someone to tell them to
have a nice day. There are a lot of lonely people in our society.
Some patients can be fairly high functioning in some life areas
and yet lack socialization skills. Sometimes, too, the world's
coldness and life's tragedies render some people alone.
Allow me to use a
comment from another teacher that I had. You know how classroom
discussions can sometimes drift? I had a teacher who one day made
the remark that loneliness is a sin. What he meant was that it is
a sin that any community leaves some its members without
companionship and emotional nurture. In social casework terms,
this seems closely related to what is meant by the concept of an
ecological system. Some people have lost or have never been
afforded the niche, the social structure, that supports their
lifestyle and liberates their full potential.
The idea of human
interdependence was expressed well by the British writer, John
Donne, in his "Devotions Upon Emergent Occasions,"
.....No man is an island, entire of itself; every
man is a piece of the continent, a part of the main.
.....Any man's death diminishes me, because I am
involved in mankind; and therefore never send to
know for whom the bell tolls, it tolls for thee.....
Some people will go
to a therapist just to have a friend to talk to. My
personal opinion is that therapy is a legitimate arena in which
the lonely can find their way. Should loneliness be a diagnosis?
If loneliness were ever to become a diagnosis, the criteria would
have to be organized such that no blame would be placed on the
victim of loneliness. Lonely patients need to borrow strength
from the ego of the therapist, find ways to connect with their
community, and develop a meaningful spirituality.
This essay is not
meant to be prescriptive. I am only writing from personal
experience. What works for me may not work for others. As I
mentioned earlier, each therapist will develop their own style
in reaching patients.
It helps me if I
conceptualize my caseload, without stereotyping or pre-judging,
into workable impressions. Diagnosis is usually necessary when
working in social service agencies, for various reasons, but
diagnosis is not the whole picture. Diagnostic categories alone,
like Donne's islands, involve neither the entire patient nor the
[*NOTE: A patient's
decision to continue harmful behavior cannot be supported by the
therapist. The therapist must remain steadfast in upholding
mental health and in the belief that the patient can make positive
changes. Also, if the patient has been referred by the courts or
other agency, the therapist is obligated to report an accurate
assessment of the patient's progress or lack of progress.
Appropriate consent forms must be obtained.]
(Written 10/06/03 - Revised 12/01/03: bibliography available.)
[NOTE: For other
essays on similar topics, see Kindness of Strangers (written
02/06/06), That's Your Opinion (written 08/02/04).]
Until we meet