Real World Clinical Blog: Nothing But the Truth

by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way 

     As social workers, we are trained in the art of understanding relativity. We honor the context of our clients’ lives. In this process, we often step aside from assumptions or hard conclusions. We work diligently to avoid an overly knowing stance, often deferring to the expertise of our clients. This is part of what makes our work so powerfully healing. We craft interventions that lead our clients to their inner wisdom and instinct. However, there are times when we need to surrender this stance, completely, in exchange for a staunch and clear knowing. There are times when our clients need definitive truths reflected back to them. It is our work to identify when to stay quiet and when to speak up, when to tell a truth, and when to yell a truth.

     We step away from the stance of relativity when our clients are in danger. This danger needs to be clearly stated. For example, let’s consider a woman who is in an abusive relationship. It is important to continuously weigh the pros and cons of remaining in this relationship. We can work to strategize safe vs. more dangerous times to leave. And, yes, we need to work with clients to create a plan that makes leaving possible.

   Oftentimes, though, what gets lost in the deliberation and meditation around the choice to leave is the precise articulation of the peril that our client is facing. We need to be able to tell clients that we think they are at risk for dying. We need to talk openly about danger, injury, and death. It is our responsibility to offer a clear and unyielding articulation of the fact that staying still will only increase the traumatic impact of the relationship.

     It is true that we need to consider our clients’ processes and bear witness to how their awareness unfolds. But this does not mean that we abandon the painful responsibility of mirroring the truth. We must speak, unrelentingly, to how high stakes and fatal domestic violence can be.

     This truth telling is particularly relevant when working with clients who have experienced sexual violence. Perhaps the violence was clearly rape, but sexual violations are rarely that simply defined. Instead, sexual intrusions can be subtle, elusive, and difficult to verbalize. Clinically, we must offer our clients relief from the psychic ambiguity generated by sexual violence.  A hallmark of sexual violence, of course, is the experience of doubting that it happened at all. Our recurring commitment to reflecting the fact of sexual violence, our refusal to doubt that it occurred, our willingness to use language to bring it into the open, is essential and ameliorative.

     A client who is going in and out of serious drug addiction also deserves the utterance of certain truths. A trait of addictive behavior is frequently denial. When someone is struggling with addiction, the risk for death comes into consciousness in fleeting moments. Our work, in these dynamics, is to hold firmly onto what has been disavowed in the service of denial. The potential consequences of dabbling in a world of deadly drug use, drugs that can easily be overdosed on, needs to be expressed. We need to tell our clients that we fear for their lives, that we dread the potential of their deaths.

     Working with children in abusive homes complicates this principle. A child in an abusive situation often has to return to that situation. Because of the child’s need to adapt to their own life and to sustain their attachments, there is a real struggle for a child to know, claim, and own their abuse. It is considerably painful, in these cases, to negotiate the voicing of truth in these cases.

     My belief is that if a child is being abused, this needs to be said aloud, to them. I hold firmly to this even if the child needs to remain in the home. I argue for this because we risk being another person in that child’s life who challenges their awareness of reality. Kids know what is happening to them, but they need adults to offer verbalization of this knowing. If we don’t crisply affirm the truth of their mistreatment, they will likely doubt it, internalize it, and long struggle for a sturdy relationship with their own perceptions.  

     Our work is so incredibly complicated. There is no end to this fact. We honor all different ways of being in the world, make use of harm reduction, refrain from judgment, occupy not-knowing stances, while building the expertise of others. Conversely, we serve as reality testers, corroborating stories that haunt our clients with doubt and insecurity. We act as auxiliary egos, helping our clients to see straight, when their vision is blurred by their life circumstances. In providing this clarity and vision, we give voice to unbearable truths when every client defense is begging us not to.

• Is my husband really dangerous? Yes.
• Can I die from relapsing on heroin? Yes.
• Is it okay for me to be alone at home when I am 5 years old? No.

     We straddle the need to remain in gray space while also screaming out what is clearly black, white, right, or wrong. While this tension can feel untenable to hold, our attachments to our clients make the necessary discernment possible. By feeling our attachments, we are guided toward what needs to be said and when to hold our tongue. We are trained to feel defended against our attachment to our clients. But the use of our attachment and the clear articulation of it can be the one thing that might save them.

     It is okay to tell your clients that you are worried about them, that you would miss them, that you can not imagine your life without them. Speak from your humanity to theirs and tell your clients what you see.

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.