Real World Clinical Blog: The Anxious Social Work Mind (Part 2)
by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way
The pervasive and insidious nature of anxiety when practicing clinical work can feel both dispiriting and disconcerting. There are many manifest (or superficial) reasons for us to feel anxious as clinical social workers. Our salaries are small and our caseloads are big. The acuity of mental illness that we see is high and the number of solutions available are low. We are trying to keep people safely afloat, often working against intricate bureaucratic systems that perpetuate ugly inequity and oppression. There are also latent, less obvious, reasons for our anxiety. These reasons are harder to articulate and easier to fix, paradoxically. Sometimes the sheer act of bringing awareness to these underlying fears can bring relief.
Is what I am doing actually therapeutic?
There is anxiety around simply having a conversation with a client. There is fear about the flow of the conversation. We worry about the presence of too much silence. We worry that it will feel awkward. We also worry that the conversation we have with a client is not actually different enough from a “regular” conversation that you would have outside of treatment. We wonder how it is different from just talking to a friend. Or, we wonder how it is different from just playing with a kid.
The fact is that it is different and isn’t. Both are okay. First, our conversations with clients are made therapeutic by the presence of our intention and thoughtfulness. Our conversations are made therapeutic by our effort to make meaning of all that is said. Our conversations are made different by our basic feelings of unconditional acceptance of our clients.
There are few other conversations that someone can have where they can talk about their criminal past, their history of abuse, their drug abuse, their eating disorder, without receiving much judgment. We do our best to listen to our clients and to help them understand themselves. Our agenda is to help them to deepen their self knowledge and gain insight into the patterns in their lives. Our conversations with our clients are probably the most supportive and open that they have in their lives.
Our conversations are also made therapeutic by the presence of our observing egos. That means that we are watching ourselves in conversation and making careful decisions. Most of the things we say, we run through a little test: Who am I saying this for? Will this help or hurt the client? Is this well timed? Is this relevant? You all have your own tests. The presence of these tests is a verification of us observing the conversation enough to distinguish it from “regular” conversations.
Conversely, though, sometimes our conversations don’t feel that different from any other conversation. This does not mean that our work is not therapeutic. We have to build a relationship somehow. I know that we all say things that make us wonder if we are “real clinicians” or “real therapists” or “real social workers.” Would a real social worker be talking about what restaurants are good or the best bus routes? I don’t know, but I think so. I think that a real social worker knows how to connect, and sometimes it takes time in totally banal discourse to get us there.
Do I feel too much? Do I feel too little?
One of the biggest sources of our anxiety is that we feel too strongly about our clients. There is tremendous shame associated with our feeling that our clients actually matter to us. Sometimes we even wish that our clients were our family or our friends. I want to emphatically normalize this. I don’t know how this experience could be avoided. I certainly don’t think that it should be. Our mind is not divided into sections where we store people, though there is a lot of fantasy about this possibility. Just think about your dream life: How many times have you dreamt about some variation of your dentist, your second grade teacher, and your rabbi all being in the same room? It feels insane, but it reveals a certain truth. We are compartment-free, and the more we rail against that, the more anxious we become.
We also get anxious when we hate our clients. We have this feeling that we are supposed to like all of our clients, to maintain a constant feeling of positive regard toward them. Then one of them does something that really enrages or even grosses us out. We think that we need to get rid of our hatred somehow, in order to really help our client. We don’t need to rid ourselves of rage and hate. Furthermore, we can’t. The mind and feelings simply don’t work that way. You can help someone even when you hate them. This hate is usually symbolic of something important. Meaning can be made of it, somehow. The hate is also emblematic of an underlying attachment issue that we can conceptualize, rather than becoming anxious about our lack of professionalism or lack of empathy.
I can relate. I can’t relate.
When we have a client whose story overlaps powerfully with our own, we almost always become concerned about our capacity to therapeutically manage the work. We fear that we will be triggered. We fear that we will be brought to a place that we can’t properly function within. With our rawer internal experiences, sometimes this is true. Most times, however, it is not true. It is precisely from our place of knowing that we can practice and think. When we know the interiority of someone’s experience, we can visit them there and be with them in it. We can bear better witness to the depths of their story.
While we fear our overlaps, we also fear the clinical spaces that we feel that we don’t know. For example, being presented with a client who has a long-term heroin addiction and chronic homelessness can feel daunting to a social worker who has never lived with addiction or socioeconomic strife. We fear that we are not the right clinician for them. I firmly believe that inside all of us there is a piece that can understand the affectual and subjective experience of another. While superficial differences can feel terrifically glaring, subtle human connection and commonality ought not be obscured. There is something in you that can connect with any client, if you dig deeply enough.
My clients aren’t getting better. My clients are getting worse.
We feel incredibly pressured to see improvement in our clients. We are pressured by our clients and agencies, alike. But sometimes, our clients don’t get better. Most times they do. Better rarely looks the way that we expect it to and is often difficult to identify. We have big ideas about what improvement means, and they are tragically flawed in their universality. No two betters look the same.
We often forget just how slow the change process is. We also forget that sometimes our clients shouldn’t change their lives, but should grow more at peace within them. There is also a lot of frustration that comes with trying to make change. For domestic violence survivors, it usually takes eight tries before they are finally ready to sincerely leave their abusers. The diagnosis with the longest treatment time for recovery is anorexia, about seven to eight years. The frequency of relapse from drug and alcohol addiction is 75%.
Old habits die hard. But strong attachments yield long standing change. Strong attachments take time to build. We need to respect this. Most change is nonlinear. The idea of two steps forward and one step back almost always needs to be applied to our work. Go easy on yourselves. Go easy on your clients. We are all trying when we have the energy to try. We are not in the “fix it” business and don’t sell home improvement supplies, because they don’t help the mind and soul. We need to be allowed to falter without feeling like we have failed. This goes for client and social worker alike.
To Self Disclose or Not?
There is tremendous anxiety and fear exerted around issues of self disclosure. We spend many sessions debating about whether or not we should self disclose. We spend other sessions regretting that we did self disclose and promising ourselves that we won’t tell anyone and we will never do it again. This is the thing about self disclosure: it isn’t THAT big of a deal. The anxiety associated with it and the significance of it are totally incongruent. We do self disclose. Every time we get dressed in the morning, we are planning for multiple self disclosures with the clothes we choose, the jewelry we wear, the fact that we may or may not wear makeup. It’s okay. You are not supposed to shift the fact that this work is ultimately one real person sitting with another real person. You can’t fight that fact and the inherent messiness that will come with it. The harder you fight it, the more ashamed of yourself and anxious you will become.
This is not work you can practice for or simulate in advance of a session, to feel more prepared. Our dress rehearsals are always the actual show. Sometimes we say too much; sometimes we say too little. Some of our interventions are more therapeutic than others. Most sessions are slow and unmemorable. Yet, some of the moments that we create, if we can shed our anxiety enough to be present for them, will be mutually magical and transformative.
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.