Some social workers are able to get clinical supervision at their jobs no charge. Many people act as through this should be free and if it is not available at their place of employment go without and delay getting their clinical license. There are some advantages to paying someone outside the agency however.
One of the advantages is that you actually get the time with your supervisor. I've had excellent supervisors who say things like "I am available whenever", but whenever never comes, or you have to ask for it. Another pitfall of supervision with your employer, is that the content of supervision is not discussing cases. It is more about all how you could do better with your paperwork, or agency policy changes, or software updates... The clinical supervision can be eclipsed by job supervision.
Another advantage is that if your are paying someone who is outside your agency, you can speak more freely about topics which could be touchy. Some of these things include: office politics or difficult relationships with coworkers, ethical issues where an agency supervisor could get defensive, and agency policies which may not be in the best interests of clients. Trying to effect change in your agency can be touchy, and bouncing your ideas around with a person who is not involved can helpful.
It is also nice to choose who you want for clinical supervision. Location and scheduling will limit your choices, but you spend a lot of time at this and having someone who is competent, and who you respect, is preferable.
Thursday, December 26, 2013
Tuesday, December 24, 2013
An Old Soul
I did intakes intake intake interiews for two 18 year old males which were one day apart, and I was having trouble keeping them straight in my mind. They had both had inpatient hospitalizations in the past year, had drug and alcohol issues, and histories which included tragically bad parents. In one case the client was hospitalized on an adolescent unit ( for which he was too old), and on an adult unit (which he was too young for). The other had just had the adolescent hospitalization, and also complained of being housed with "kids". They both had diagnoses for major depression and were on similar medications, but one client felt the medication helped, the other thought it was not helpful. Both of these guys were likeable, interested in getting better, and amenable to therapy (not always the case for age 18). One had age appropriate hopes and dreams. He wanted to go cross country to California or Colorado, maybe even Finland (because of proximity to the Arctic Circle). he had a job involving fast food and was living with grandparents.
The other guy was different. I even wrote in my intake notes "seems older than identified age". This guy said he had several bad relationships with girls, but was now in a relationship that is more equal and likely to succeed. He was attending 8-9 AA meetings a week, had a sponsor, and a 6 month chip. He was able to identify triggers for relapse and had good strategies for avoiding or handling them. he was able to describe a how he resolved a difficult situation with his mother where he was respecting boundaries and taking ownership for his part of the interchange. He also had a business plan which was logical and seemed like it could succeed. There was a lot of maturity that I don't typically see in clients, but it was his eyes which convinced me that he was an "old soul". They were a milky blue and had not only seen a lot of life, but had a transcendent quality. he had seen a lot of life in his 18 years, but he seemed older than that.
Sunday, December 22, 2013
Adult ADHD
I've worked with children with ADHD diagnoses before, and have some opinions about that. I've seen kids which fit the criteria and seem to have something organic going on, and also kids who meet the criteria who come from "situations" where if they had some consistency in their lives the whole thing might just go away. I have also had adults who claim to have ADHD who I think kind of like the meds, or maybe the diagnosis is trendy...
I had a new client who was middle aged and came in and said he was diagnosed as an adult with ADHD about 6 years ago. I already know that our psychiatrist believes "ADHD must be diagnosed as a child, or it can't be ADHD", so I'm listening closely and critically to this guy. Keep in mind that when he grew up in the 60s, kids who couldn't sit still were sent to the principal's office, or kind put into a group where they wouldn't bother other kids. In the case of my client, both parents worked in his private school, and his Dad was the principal. He had trouble, but he never got too many negative messages because his parent s could run interference for him. His grades were all over the place. When he got to college, and was expected to be more responsible, he couldn't manage his time and dropped out after a year. He married, had kids, and bought a house. He had a succession of jobs with which he had success, but only when he had the right kind of supports. His wife tended to like to manage his schedule, and that worked for a while. He had enough success to upgrade from a starter house to a better house, and send his kids to college. Then something unraveled in his marriage, and he divorced. He ended up in the office of an area psychiatrist who diagnosed him with ADHD, combined type and put him on meds, at higher doses than is typical, and he improved. (this particular psychiatrist has a reputation for prescribing heavily). The client was able to tell me in detail what was different for him, like each particular task that he couldn't do without meds, and how being able to perform one step of a task (on meds), gave him the ability to complete the whole activity. The guy was intelligent, articulate and knew more about ADHD than most professionals (including me). I learned a lot from this client, but the intake was difficult for me to write up. Because of where I work, I am always on the look out for people who are drug seeking, and I already know the opinion of our psychiatrist about ADHD adults.
I gave him the ADHD combined diagnosis there was nothing else on Axis I I could consider (with the information I had). I will find out what the psychiatrist thinks in a few weeks when he has his psychiatric evaluation.
I had a new client who was middle aged and came in and said he was diagnosed as an adult with ADHD about 6 years ago. I already know that our psychiatrist believes "ADHD must be diagnosed as a child, or it can't be ADHD", so I'm listening closely and critically to this guy. Keep in mind that when he grew up in the 60s, kids who couldn't sit still were sent to the principal's office, or kind put into a group where they wouldn't bother other kids. In the case of my client, both parents worked in his private school, and his Dad was the principal. He had trouble, but he never got too many negative messages because his parent s could run interference for him. His grades were all over the place. When he got to college, and was expected to be more responsible, he couldn't manage his time and dropped out after a year. He married, had kids, and bought a house. He had a succession of jobs with which he had success, but only when he had the right kind of supports. His wife tended to like to manage his schedule, and that worked for a while. He had enough success to upgrade from a starter house to a better house, and send his kids to college. Then something unraveled in his marriage, and he divorced. He ended up in the office of an area psychiatrist who diagnosed him with ADHD, combined type and put him on meds, at higher doses than is typical, and he improved. (this particular psychiatrist has a reputation for prescribing heavily). The client was able to tell me in detail what was different for him, like each particular task that he couldn't do without meds, and how being able to perform one step of a task (on meds), gave him the ability to complete the whole activity. The guy was intelligent, articulate and knew more about ADHD than most professionals (including me). I learned a lot from this client, but the intake was difficult for me to write up. Because of where I work, I am always on the look out for people who are drug seeking, and I already know the opinion of our psychiatrist about ADHD adults.
I gave him the ADHD combined diagnosis there was nothing else on Axis I I could consider (with the information I had). I will find out what the psychiatrist thinks in a few weeks when he has his psychiatric evaluation.
Saturday, December 21, 2013
The First Holiday without a loved One.
The first year of holidays after a friend or family member dies is usually very difficult. (actually the second can be as bad or worse) Most people acknowledge that that, but when clients are in therapy they sometimes give a voice to what they really fear. Reactions can be complicated and confusing, especially if the the relationship wasn't 'all good", but mixed or down right problematic.
What a lot of people have said to me is "I can't do it", "it is going to be too hard', or "I'm afraid I'll start crying and won't be able to stop". I have at least 4 clients who are having their first holiday without a loved one, 3 who have lost parents and one who lost a twin brother. One client who lost her Mom had a reasonably good relationship. The others had complicated situations. They are unsure of how to memorialize their relative and say things like "I'm not sure if I loved him or not" and admit in therapy that the person wasn't perfect, had a dark side, or did something that was hard to forgive.
I encourage clients to do an activity or ritual to kind of experience the feelings. Any activity that has a beginning and end seems to give the feelings a time and place so that people can participate in some other part of the holiday and be fully present. Sitting in a chair and crying may also occur, but the "doing' something seems to work for many people. And because the planning of this "doing' takes time and thought, there is a little less time to worry about "how will I get through this?".
What a lot of people have said to me is "I can't do it", "it is going to be too hard', or "I'm afraid I'll start crying and won't be able to stop". I have at least 4 clients who are having their first holiday without a loved one, 3 who have lost parents and one who lost a twin brother. One client who lost her Mom had a reasonably good relationship. The others had complicated situations. They are unsure of how to memorialize their relative and say things like "I'm not sure if I loved him or not" and admit in therapy that the person wasn't perfect, had a dark side, or did something that was hard to forgive.
I encourage clients to do an activity or ritual to kind of experience the feelings. Any activity that has a beginning and end seems to give the feelings a time and place so that people can participate in some other part of the holiday and be fully present. Sitting in a chair and crying may also occur, but the "doing' something seems to work for many people. And because the planning of this "doing' takes time and thought, there is a little less time to worry about "how will I get through this?".
Friday, December 20, 2013
Call the Midwife
I started watching "Call the Midwife" on Netflix and just love that show. I'll admit that I sometimes fast forward through the live birth scenes when women are in labor too long (my husband won't watch it at all). If your not familiar with this show, it is set in London's East end in the 1950s and is based on the memoirs of Jennifer Worth, a young midwife. What I most identify with is the "Why did I ever start this?" that flashes on the screen at the beginning of each episode. It is her sense of being in an different culture, with a different way of life, right in London where she grew up. The main character, Jenny, is constantly put into situations that are strange, uncertain, and challenging, and she becomes more confident with each situation she handles and deeply touched by he people she works with. But my favorite character is actually "Chummy". I love her attitude and the way she makes decisions, sometimes reversing them shortly after they are made, and is always able to maintain a sense of humor.
Thursday, December 19, 2013
Issues of Safety
There were a few clients for which safety became the topic of the therapy sessions. And I handled this OK, reaching for what clients do to make themselves safe, times in the past when they have had relative safety, or lacked safety, and survived. Underneath all that I was personally worried about my safety as well. I was on the second floor of the building and from time to time I found myself as the only person on that level. The agency provided each therapist with a flashlight with a plastic whistle attached. There was a security guard in the waiting room on the first floor, but he was of the "looking half asleep" variety. I'm not sure how quickly he could respond if needed. We had no discrete panic button or anything.
The whole job seemed a bit "iffy" and for the first two or three days I did not leave anything at the agency just in case I would decide not to come back. But eventually I put personal things on my bulletin board, hung pictures on the wall, and put up curtains. There were more shootings, especially during the hot weather and I did not leave the building except to go to my car. I was hard to have sessions with clients when there was police activity in the streets. But believe it or not, I eventually got to where I could tune it out (mostly).
The whole job seemed a bit "iffy" and for the first two or three days I did not leave anything at the agency just in case I would decide not to come back. But eventually I put personal things on my bulletin board, hung pictures on the wall, and put up curtains. There were more shootings, especially during the hot weather and I did not leave the building except to go to my car. I was hard to have sessions with clients when there was police activity in the streets. But believe it or not, I eventually got to where I could tune it out (mostly).
Wednesday, December 18, 2013
An Inherited Case Load
When I started at my agency I inherited a caseload of 45+ clients from a previous therapist. I also inherited her office. Fortunately she had terminated with clients before she left, but I think it was still difficult for some clients to come in to the agency, to the same office, and have someone sitting in the previous therapist's chair. Some clients transitioned well, and others not so well. A few refused to schedule with me at all.
I learned a lot about the previous therapist from the clients who continued with me, and that taught me a few things. The previous therapist left because someone was shot across the street from our office. She explained to the clients that she was leaving because the neighborhood was too dangerous. I think she had several reasons for leaving, but it seems that she thought that the shooting would be a good one to tell clients. She also self-disclosed to her clients a great deal, and they knew about her feelings about the drugs and prostitution in the center city area.
This was not a good message for many of my clients. They actually do not have the opportunity to opt-out of their neighborhood. Many have lived for long periods in either this area or in other cities with similar issues. She unwittingly gave the message that the neighborhood that they were a part of was not to her liking, and she could choose not to work with them. This bothers me even more now because many of my clients are (or previously were) drug dealers, prostitutes, or people who participated in the violence.
I also learned about the dangers of self-disclosure from these clients. Over the course of a few months I learned more than I should have about the previous therapist. She shared details of her religious beliefs, politics, her personal mental health issues, and issues having to do with the agency that the clients had no business knowing. Any social worker who self-discloses should be aware that confidentiality is not a two-way street.
I learned a lot about the previous therapist from the clients who continued with me, and that taught me a few things. The previous therapist left because someone was shot across the street from our office. She explained to the clients that she was leaving because the neighborhood was too dangerous. I think she had several reasons for leaving, but it seems that she thought that the shooting would be a good one to tell clients. She also self-disclosed to her clients a great deal, and they knew about her feelings about the drugs and prostitution in the center city area.
This was not a good message for many of my clients. They actually do not have the opportunity to opt-out of their neighborhood. Many have lived for long periods in either this area or in other cities with similar issues. She unwittingly gave the message that the neighborhood that they were a part of was not to her liking, and she could choose not to work with them. This bothers me even more now because many of my clients are (or previously were) drug dealers, prostitutes, or people who participated in the violence.
I also learned about the dangers of self-disclosure from these clients. Over the course of a few months I learned more than I should have about the previous therapist. She shared details of her religious beliefs, politics, her personal mental health issues, and issues having to do with the agency that the clients had no business knowing. Any social worker who self-discloses should be aware that confidentiality is not a two-way street.
Tuesday, December 17, 2013
Where I Work
I work in an outpatient community mental health agency. We are in an old house located smack in the neighborhood where our clients live. We have 5 therapists, a psychiatrist, and a nurse practitioner plus 2 secretaries and a guy who does drug and alcohol outreach. Everyone is Hispanic save me and one other therapist, and our psychiatrist is from Pakistan. A good bit more than half of our clients are Hispanic, primarily with origins in Puerto Rico and the Dominican Republic. Most come to us by way of New York City and many have family in the Bronx or Brooklyn as well as having relatives in the Caribbean. We are in Eastern Pa, which is about an hour and a half from NYC. This part of Pennsylvania has been traditionally white, with most people having either German or Irish roots. The influx from New York has been going on for about 10-15 years.
Everyone in the office is bilingual, except for one therapist. Almost all of my clients are bilingual as well, and there is a great deal of language switching all day, every day. I have 5 or 6 clients who are Spanish only, and have had sessions which begin in Spanish and switch to English part way through. It is kind of interesting to say the least.
Everyone in the office is bilingual, except for one therapist. Almost all of my clients are bilingual as well, and there is a great deal of language switching all day, every day. I have 5 or 6 clients who are Spanish only, and have had sessions which begin in Spanish and switch to English part way through. It is kind of interesting to say the least.
Sunday, December 15, 2013
A bilingual social worker
I wasn't always bilingual, and I haven't been a social worker for very long. After my youngest child got his driver's license I decided I wanted to finally do something more in my life. I don't like to be bored and the idea of a soon to be empty nest did not sit well with me. I had my undergraduate degree in Psychology, but to get an advanced degree in that field was daunting. I decided on an MSW without fully understanding what it was I was getting into. The one thing I did know is that it would qualify me for jobs working with people. It turned out to be one of the best decisions of my life. It's actually hard to believe I didn't find this out earlier.
The bilingual part came late in life as well. During my first few semesters of graduate school I heard people say over and over, that there was a demand for social workers who speak Spanish. I had a lot of college Spanish and always got As, but that was decades in the past. I also was very timid about speaking. I don't like to make mistakes and am shy in most situations. I still had a lot of Spanish books in the attic and I went and found them. I had spent 2 weeks in Cuernavaca Mexico in the 1990s at a total immersion language school. I got online and found that the school that I had attended was no longer in existence, but there several others. In the summer of 2011 I signed up, got on a plane, and went to Mexico for 3 weeks. I had forgotten most of my Spanish but was placed in a low intermediate class. Learning it a second time took less time, and I found that I remembered a lot of vocabulary a some of the grammar. Since then I have been studying by reading as much in Spanish as I can, studying online with Skype, and visiting Cuernavaca. I have tried a couple of online classes and now I study with Maru Cortes of ASLI Spanish Language Institute in Cuernavaca. I also listen to audio books in Spanish which can be found on Audible. They are a great value, and also convenient.
The bilingual part came late in life as well. During my first few semesters of graduate school I heard people say over and over, that there was a demand for social workers who speak Spanish. I had a lot of college Spanish and always got As, but that was decades in the past. I also was very timid about speaking. I don't like to make mistakes and am shy in most situations. I still had a lot of Spanish books in the attic and I went and found them. I had spent 2 weeks in Cuernavaca Mexico in the 1990s at a total immersion language school. I got online and found that the school that I had attended was no longer in existence, but there several others. In the summer of 2011 I signed up, got on a plane, and went to Mexico for 3 weeks. I had forgotten most of my Spanish but was placed in a low intermediate class. Learning it a second time took less time, and I found that I remembered a lot of vocabulary a some of the grammar. Since then I have been studying by reading as much in Spanish as I can, studying online with Skype, and visiting Cuernavaca. I have tried a couple of online classes and now I study with Maru Cortes of ASLI Spanish Language Institute in Cuernavaca. I also listen to audio books in Spanish which can be found on Audible. They are a great value, and also convenient.
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