Friday, October 15, 2010

Integrating Theory With Practice

       
Since my last post, I have been essentially settling into the routine of seeing between 8 and 9 patients a week at my placement in addition to the twice weekly group sessions, the weekly social work seminar and the other routine fixed weekly items on my agenda.

The work that I am finding the most challenging for now includes the steps that you need to be keeping in mind as a therapist above and beyond listening and being empathetic to the client.

These include noticing the defenses that the client is employing, any discrepancies between the client's body language and what she or he is saying as well as any transference or counter-transference that may be occurring. For a brief explanation of transference, counter-transference and defenses, please see Social Work Internship: 2nd Week.

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Further compounding things, is that in an ideal situation, I should not only be noticing on the spot any defenses that the client may be employing, but I should be confronting the client employing the defense at that same time.

For example, when a particular client was telling me that she had "only" cut herself three to four times over the past four years, I had the feeling that she was either minimizing the number of times she had cut herself or she was in denial of how bad a problem she has in this regard and I put a note to this effect in my process recording.

My supervisor pointed out that if this is what I felt, I should have brought this feeling up with the client to see what her response would have been as opposed to having just had this feeling and/or making this observation in my process recording.

This is in fact what I did when I saw the same client during a subsequent session. She then changed her figure from 3 or 4 times to 5 or 6 times and importantly I learned that there were other things she did when she got angry such as punching her thighs or throwing things.

Generally-speaking, I do not think I tend to detect clients employing defenses while they are talking to me one-on-one. Is this because I am not used to listening for this nuance? And/or it takes practice until you automatically pick up on them? At the moment, if I do pick up on something, it is almost on an unconscious level and it's something that will come to surface as I'm writing my process recording of a particular session.

That said, I have noticed defenses employed by clients in group sessions when I am not concerned about needing to remember the content of the discussion for a subsequent process recording. Perhaps my efforts to ensure the recall of my sessions for either the process recordings or progress notes are interfering with my observations of the client's defenses.

This suggests that maybe I need to try to relax more about the content part so that I can be naturally receptive to the defenses employed.

With regards to the body language area, if a client is making a facial expression that seems like a mismatch to the feeling she or he is expressing, once again I am not just to make note of this but to say something to the client.

An example in the body language/observation arena may be that if a client came in with dark glasses, it would not be ok for me to just note this but I would need to confront the client and say that I see that she or he has come in with dark glasses - it makes it hard for me to see her/him...what is the reason she/he chose to wear dark glasses?

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Moving onto the third difficult area of transference and counter-transference, here too, it is not enough to note feelings of transference and counter-transference when they occur. As the clinician, you must make sure not to let those feelings interfere with your work with the client.

I find detecting the transference the client has towards me difficult to discern; similarly, I may be totally unaware of own counter-transference at times.

For example, with one client, my supervisor noted that I seemed to have let myself get off topic by the the client and she pointed out that this suggested a counter-transference on my part but I don't know of what? or by whom so how do I prevent this from happening again?

That's the update. I would really appreciate your advice and/or suggestions...

Were/are these concepts also hard for you at the beginning to integrate into your work? Do you have any advice on how to overcome these challenges?


You May Also Enjoy:
Social Work Internship: 2nd Week
Beginning of 2nd Year Internship 
Social Work Licensing – Part I
Embarking on a New Career

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11 comments:

  1. Note how you feel. Is it different than usual? How? What does that tell you about the other person? Does it change? Does it change when you make an intervention? How?

    This knowledge helps you solve the puzzle sitting in front of you.

    The most difficult skill to learn is probably how to time your interventions.

    The rule is not really to say what you feel when you feel it.

    The guideline is that all interventions should deepen the discussion and produce more material. If they do not, they were either poor or poorly timed interventions.

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  2. Interesting perspective Dorlee. Great post!

    May I add that defenses are necessary for some people to survive and avoid fragmenting. Therefore, the difficulty lies with the therapist in determining when/if a defense should be confronted and will it benefit the client in the long run?

    Sounds like you are learning a lot and also doing a great job! Congratulation:)

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  3. Dear Anonymous,

    Thanks so much for your explanation and guidance regarding the application and timing of interventions.

    What you are saying makes a lot of sense...it also makes me feel better about my needing more time to integrate what I am learning and seeing about the client.

    For example, I have one client who uses the expression "I'm going to be honest" or "I'm going to tell you the truth" a lot.

    While I had noticed this the first time we met, I only asked her about why she thought she was saying this during our third session after I saw that she uses this expression rather consistently and felt that she would not feel threatened by my question.

    Her first response did not yield the answer, so to speak, but as we continued to talk, I learned that she used to lie as a child to her mother as well as later in school - thereby, illustrating, as you mentioned, a well-timed intervention b/c it deepened the conversation.


    Dear Laurel,

    Great minds think alike...you seem to be saying something very similar to what Anonymous is explaining - one should only confront a defense if/when it is one that may benefit the client in the long run.

    Interestingly, that nuance has not yet been pointed out to me in supervision. This may be as a result of the fact that my supervisor is first trying to teach me to be alert to the defenses being used and that is a skill in of itself to develop.

    Thanks so much for your expert guidance and encouraging feedback :)

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  4. Dorlee,
    Wow, what an intriguing post; I feel I am learning through (and with you, to a certain degree) as you "integrate theory with practice").

    That you are seeing 8-9 patients a week is impressive to an outsider like me, peering in. Moving from the classroom to real-life patient care sounds so meaningful and exciting.

    As well, this portion of your post really struck me:

    Generally-speaking, I do not think I tend to detect clients' employing defenses while they are talking to me one-on-one. Is this because I am not used to listening for this nuance? And/or it takes practice until you automatically pick up on them? At the moment, if I do pick up on something, it is almost on an unconscious level and it's something that will come to surface as I'm writing my process recording of a particular session.

    What great "self-insight" and exploration. It sounds to me like all this nuancing and unconscious level thinking, as well as surfacing of insights will become second nature ... over time.

    I applaud you and am impressed by your ability to move through this process, internship and thoughtful introspection on a day-to-day, learning and growing basis.

    Wonderful post!

    Jacqui

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  5. Hi Jacqui,

    I'm so glad you enjoyed the post :)

    Thank you so much for your very enthusiastic feedback and encouragement as I go through this learning process.

    Putting into practice all the theory is much harder than I thought it would be and it can feel a bit overwhelming and frustrating at times - particularly because I would like to be able to do/know it all from the beginning.

    This means that I need to add patience for the learning process to my portfolio of skills :)

    However, at the same time, the change, growth and challenges are all very exciting...

    Thankfully, I do seem to be blessed (so far) with being able to engage with my clients almost intuitively very well from the beginning - including one client whom I had been forewarned that I will really have to work hard on with to get that client to talk etc.

    This gives me the feeling that I'm on the right track despite all the things that I need to learn based upon the feedback I receive on my process recordings.

    I really appreciate your kind support,
    Dorlee

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  6. Sounds like you are getting lots of great experience, Dorlee!

    I want to second what several people have said--confronting defenses requires judgment about which ones to confront and when. Defenses are there because they have been helping the client. In fact, I would go so far as to say that almost all of the time, defenses make a huge amount of sense when you understand what a person has lived through.

    Being aware of the moment by moment unfolding of a session takes a huge amount of mindfulness--it's easy for our anxiety or preoccupation with remembering can interfere with this. We need to be mindful of what the client is doing and of how we are feeling in reaction and then use this information to make choices about what to say and do (or what not to say and not do). Developing this awareness and skill takes practice, but there are things you can do that can help you learn this faster: I would recommend practicing mindfulness in your personal ilfe. In addition to helping you in your therapy I think you'll find many other personal benefits. There are many good sources to learn mindfulness; here's a video by Jon Kabat-Zinn http://www.youtube.com/watch?v=3nwwKbM_vJc to get you started. He has many good books/CDs out: Full Catastrophe Living outlines his mindfulness education program. Searching on mindfulness meditation will also bring up lots of good results from many other people. Practicing as little as 10 min a day can bring benefits.

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  7. Thanks so much for your valuable guidance, Nancy.

    I also really appreciate the resources that you periodically refer me to :) How interesting that increasing one's mindfulness in one's personal life can help with one's ability to conduct therapy...

    But as I'm thinking about it, what you are recommending makes a lot of sense. The more one is able to be in the present, the more one would be able to notice everything that is occurring (and the less likely one would be to miss something).

    I will definitely try this out.

    Thanks again!
    Dorlee

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  8. Mindfulness is one of those qualities that when you strengthen it, you take it everywhere. I'll be interested to hear how it works out for you!

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  9. Thanks! After I'm doing it for a few weeks, I'll make sure to let you know :)

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  10. Hi Dorlee

    This is Hannah, from Singapore. I'm doing my final year social work internship & was surfing the net for articles on 'transference & counter-transference' when I came across your blog. Thank you for sharing...it helps validate some of the internal tension I'm experiencing coz the cases I encounter at my internship triggered much pain...I'm hanging in there...
    Noticed the post was dated Oct 2010, hope my post reaches you.
    Take care,
    Hannah.

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  11. Hi Hannah,

    I'm sorry to hear that some of the cases you are handling at your internship are triggering much pain for you...but am glad to hear that some of the posts that I have shared are helping you to face and deal with some of the issues that are arising for you.

    Hang in there...as you get to know yourself better and heal yourself as well as understand what you can and can't do for your clients, you will find a middle road that works for you and helps your clients.

    Please feel free to write or ask questions. I am here :)

    I also hope that you are able to talk to your supervisor as well as a therapist about the various feelings that are coming up for you. This is an important step that also helps during this training journey.

    Wishing you all the best,
    Dorlee

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