by Dr. Danna R. Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way
Eye movement desensitization and reprocessing therapy, dialectical behavior therapy, cognitive behavioral therapy, trauma focused cognitive behavioral therapy, individual education plan, attachment based family therapy, mindfulness based stress reduction, multi systems family therapy, diagnostic and statistical manual, borderline personality disorder, evidence based practice, and you, the MSW.
In thinking about writing this post, I started to think about all of the initials that we have to identify the treatments and interventions that we are supposed to use. Of course, we all know that we should be doing some sort of EPB. It used to be that the “most” evidence based practice was CBT, but now we have TF-CBT, which is great for kids, but if you have someone with BPD, you should use DBT, because that is more of an EPB. If you are working with families, MST used to be in vogue. Now there is focus on ABFT with a touch of MBSR. But you must really consult the DSM to decide how to best proceed with an IEP.
I am not saying any of this in jest, but it can start to feel quite silly. It can feel both quite complicated and reductive at the same time. It can feel confusing, because the pressure to produce “measurable” results from these interventions keeps growing alongside the pressure to adhere to a specific modality or theoretical orientation. I think it can leave us, often, wondering what we are doing at all and if we are doing it “right." In fact, the more prescriptive the intervention, the more likely we are to feel like we are going off script and thereby getting it all “wrong.”
So, what are we doing? I think that the answer, of course, varies client to client and clinician to clinician. However, I think that there are some powerful and unifying themes that we ought to be adhering to and, really, refusing to get distracted from. There are three central things that I am working on doing at all times, though it might not always seem obvious or like it is even happening at all. These things are: increasing emotional literacy, offering containment, and shifting toward a secure attachment style.
Tremendous relief often comes for people when they recognize that they are having feelings, for these feelings to be named, and for the feelings to be witnessed and truly experienced. It can be surprisingly difficult to even identity the presence of a feeling for several intricate and subtle reasons. First, a feeling can only be understood if it was originally mirrored by a caregiver. For example, a kid could fall and cry. The caregiver could say, “It doesn’t hurt, come on, just get up." Or a caregiver could say, “Oh, that must have been scary and really hurt." The responses lay the groundwork for future attempts to understand our own internal, emotional worlds. Secondly, defenses often obscure our access to emotions because something in us is saying that the emotion will be too scary to experience. Or we fear that the emotion might even annihilate us in some way. This is why some might opt for denial, dissociation. or intellectualization. It is not necessarily a conscious choice, but it is one that severs us from the deep knowing that comes from saying and facing our emotions.
So many of our interventions can be distilled down to the simple question: “How does that make you feel?" We return to this question in the hopes of enhancing emotional literacy, increasing the awareness of the geography of one’s own mind. This deepened awareness leads to a freedom and a mastery. It is initiated by the curiosity of an other (us), and transformed into empowerment and self knowledge for our clients.
Another central task in our clinical work is to offer containment. We have clients who come in worried, afraid, anxious, and even disorganized in their understanding of who they are. We have clients who have a terrifically hard time integrating varying pieces of themselves and their experiences into their psyches. Their time with us serves as a resting place for their psychic trouble. We offer the time, the space, and the steadiness to receive our clients fully.
For example, if a client has just experienced a surprising loss of a loved one, their brain has not yet accommodated to this reality. They wake up surprised about it having happened, and when they remember the loss, it can feel like a sudden jolt. Even if there are just minutes between the remembrance, that jolt is there. Clinically, we serve to contain them. We hold the information that the loss indeed occurred, that they will survive, and that their mind will eventually habituate to it. It is our keen awareness of their ultimate survival, coupled with our presence, curiosity, and tenderness, that allows for the evolution of their own ability to contain the pain and vicissitudes of their own mind.
Moving someone from an anxious or avoidant style of attachment is not particularly complicated, though it is not easy. It requires a steadfast commitment to predictability, transparency, and adherence to the frame that is provided by our work. If we are prescribed a 45-minute hour by our agency and this is what we consistently work with, this helps to shift attachment. If we demonstrate that we remember what our client talked about last week, this shifts attachment. If we don’t overwhelm with our presence, but don’t disappear either, this shifts attachment. The more assuredly that we demonstrate that we have internalized our clients and their stories, and the more consistently that we show up, the more powerfully we can impact and shift their expectations about how attachment ought to go.
The alphabet soup matters. A lot of wisdom and research have gone into the discovery of different ways of practicing, thinking, and being. But, don’t let it divert you from the complexity of the basics, and the simplicity required to sustain and build human connection.
Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way.