by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way
I used to think that all of my clients were going to end up in graduate school - not just college, but graduate school. Although this was clearly a narrow view of things, and a fairly narcissistic one, it was my way of thinking that anyone can do anything. Sure, I was aware of the idiosyncratic desires of each client, but this was my way of honoring infinite possibility and wellness for anyone. I have come to understand many things since this original naïveté. Some of these things have to do with the futility of graduate school, but more significantly, I have come to understand the substantial variations in the presentation of progress and wellness.
We have clients with all different levels of functionality, of course. Since my initial graduate school for all fantasy, I have learned how hard it is to recognize both a client’s strengths and real suffering in equal measure. I have clients who have begged me for years to see how much pain they are in and how limited they feel in their functionality. I have also had clients who have asked me to understand the level of satisfaction that they feel in their lives, even if I can’t understand where that satisfaction is coming from.
To work with clients, from both a strengths based perspective and in a diagnostically and socioeconomically precise way, we must listen beyond what we have the capacity to hear. In a recent case conference, we reviewed a case of a client who has been talking about the possibility of his own space travel for years. He intends to spend some time on Mars and bring his discoveries back to earth. He has no money, is often hungry, and is in poor health. At 45, he also has no education. Clearly, his goals are unrealistic. So what? He comes to meet with his social worker weekly, but no progress seems to be made. He just talks and talks and talks. She is often bored and frustrated. Where will the wellness come, and what will it look like?
During a recent session, he was talking about his strong political leanings, assuming the therapist felt the same. She felt invisible and enraged. The following session, she returned to say that she actually didn’t agree with all of his viewpoints, but was always open to hearing what he had to say. She felt it was essential to assert the fact of her existence in his life, in his mind, in his presence. He didn’t blink when she said it, and he returned to space travel. She was dispirited and disillusioned. The next session, he came back to say that he had thought about what she said and he was grateful that she had shared her point of view.
To me, this is a tiny act of growth and wellness. Or maybe not so tiny. The client, in his psychological machinations, was operating from a highly narcissistic place. His ideas for his future are grandiose, and his capacity for relatedness is deeply diminished by his fantasy life and his struggle with self esteem. After endless sessions of reflective listening, a quintessential intervention for many narcissists who are struggling to locate and refine their senses of self, he was able to recognize another - an other. For this client, the path toward wellness might be the simple experience of moments of relatedness. Not necessarily a life of relatedness, but moments of it.
For every client, clearly, treatment goals and paths toward wellness or relief look different. The loftier our clinical goals are, the more likely we are to miss essential strides toward change and maturation. Sometimes, it feels painful to recognize the limitations of how much someone can change. Other times, it is actually generous to do this, because it is a complete honoring of the gravity of their internal struggle. I don’t think someone with an extreme eating disorder will ever eat with complete freedom. Does this mean that I am giving up on them? Or does this mean that I am seeing them clearly?
Perhaps as we practice, over time, we may feel more cynical. But, really, I think it is that we become generously attuned and realistic. And, in this realism, we also understand that diversity in functionality is diversity in wellness. The more that we surrender a homogenic vision of what functioning or normal looks like, the more open to the vicissitudes of it we can become. Further, distilling our perception of wellness to something more simple can enhance our work.
I have come to think of my hope for all clients, now, as the capacity to attach. It was once graduate school, a privileged and monolithic notion. It is now attachment of any kind - to a pet, a type of food, a home, a friend, a dream. I have come, now, to recognize that the pulse of change can be measured by the ability to connect. Measuring the often subtle, and barely audible, diverse ticking of this pulse is where my work now lies.
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. Read more about clinical supervision in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.