Last night in our training clinic, I watched one of our grad students conduct an intake interview with a 17 year old who was recently expelled from school. The idea of expelling kids from school makes me ill to start with, so I watched with a grumpy face. As the session unfolded, I only felt more angry and irritated. This 17 year old kid told the grad student that he was being expelled over, “a lot of little stuff” like tardies, disrespecting teachers, not doing work, etc. I’m not naive enough anymore to buy that story without checking it out with the school, but it was still disturbing. It could be true.
To complicate matters another step, this particular kid is Black, big for his age (athletic big, not fat big) and wore his hair shoulder-length and braided. He spoke very quietly, even after his great-grandmother, who is his guardian left to return to the waiting area. I could easily imagine this guy could scare the crap out of a teacher without really trying, just by being so tall and muscular. But being scared of a kid because he looks like he could tackle you with one arm doesn’t make it ok to throw him out of mainstream society.
[Didn’t you know that’s what expulsion is? Read more here: http://www.ed.gov/news/press-releases/expansive-survey-americas-public-schools-reveals-troubling-racial-disparities]
I know the U.S. government in general, and the states in particular don’t quite comprehend the problem, but it’s really pretty simple. Here’s the deal, in a simple geometry-ish proof:
1. There is a strong relationship between school failure and life failure (e.g., going to prison).
2. Some kids are at much higher risk than other kids for school failure. We know who they are. We’ve known this for decades (poor, black or brown boys, little to no adult support at home, bad neighborhoods, toxic stress, abused, neglected, and generally stressed out kids).
3. We know that when kids in #2 are given certain types of early and frequent intervention, they are much less likely to fail at school.
4. If they don’t fail at school, they have a hell of a lot better chance at staying out of prison.
5. If they don’t go to prison, they can get jobs. If they work, they pay taxes.
6. If we spend a little money now on those interventions in #3, we will have greater tax revenues in the future.
7. Investing in appropriate educational interventions for stressed out kids literally pays off.
QED, asshats in office. We need intervention for stressed out kids. We need it early. We need it often. We can not wait.
Back to the kid in my opening paragraph. I really hope he comes back. He said he would, but in my experience, it’s about 50/50 with adolescents in trouble who live with folks who aren’t their parents. Great granny looks like she’s about 80. I don’t know that she has the energy to make him get his act together. The kid seemed interested in doing things differently, but also seemed very doubtful about being able to make it happen. I fear we’ve lost this one, mostly due to this dubious expulsion. It’s way past time to stop expulsion.
Amy Bank’s first book, “Four Ways to Click” (2015) New York: Tarcher/Penguin, distills the wisdom of the magnificent Jean Baker-Miller’s theories, infuses them with a new dose of relevance and importance via recent neuroscience findings, and pours out information written for a general audience. Dr. Banks, who is also a practicing psychiatrist, had some help from professional writer Leigh Ann Hirschman making these ideas come across in such simple and basic language, and I’m very grateful for that. I’ve been at a few training sessions Amy has led over the years, and I always leave feeling like my brain has over-indulged, much like my tummy feels right after Christmas dinner. Her ideas are brilliant, and in this new format, even normals like myself can get a firm grasp on them.
True to its title, the book breaks Dr. Miller’s Relational-Cultural theory (RCT) ideas down into four basic bites: Calm, Accepted, Resonant, Energetic (CARE for short). Each of the four bites,which she calls pathways, has its own chapter, where Amy explains what brain and nervous system parts have to engage to make that bite happen. She also tells us what emotional and behavioral symptoms emerge when that part is out of whack.
Two other key components of this book are the “3 rules for brain change” and a self-scoring assessment readers can use to determine how well balanced (or not) they are with the four basic relational pathways (The CARE parts). The three rules aren’t new to anyone who’s been reading the newer neuroscience books, especially the applied texts. The rules all relate to basic science about neuroplasticity, or what it takes to create new automatic or default thoughts and behaviors. It really boils down to the fact that you have to practice – a lot- to make changes permanent. It’s nice to have the brain science explained, although telling readers to practice a lot would be ok, too.
The self-assessment is pretty handy. It doesn’t purport to be psychometrically sound, which is fine, since it’s not being used as a true diagnostic tool. I was surprised that there doesn’t seem to be (unless I overlooked it) any reference to Liang,et al and the Relational Health Index, which has been around for several years and is quite similar to this scale. Amy’s CARE Relational Assessment is tailored to fit within her framework, while the RHI is designed to fit under the more broad RCT frame. I don’t know the back story on this part of the book, but it does make me scratch my head a bit. The RCT world is small and deeply connected. Amy took pains to thank a lot of people in the acknowledgements section, but the RHI team aren’t there.
I found this little volume (it’s only about 300 pages, with the index, notes, table of contents, etc.) to be very accessible, and I imagine that clients who have at least a 10-12th grade reading level would find it interesting and helpful. I read most of it while waiting for an oil change to be completed, and found it very engaging. I’m encouraging my graduate students to pick it up as a good resource to recommend to their clients who are struggling with out-of-whack neural/relational pathways. It’s a nice introduction to how the brain influences and reflects our relationships, and understanding that interplay can be a life-changer for clients.
My mama says lots of memorable and useful things. One of her best is about the periodic need people have for repotting. If you’ve ever had a house plant, or a garden, you know what happens when you get lazy and let the thing grow so big that the roots end up molding themselves to the pot. The same thing happens to people. Some experience it more often than others, but at some point, we all feel the need to move into a new pot. Our roots get all bound up. We can’t get enough spiritual nutrients. We begin to droop. Mama says, it’s time to repot yourself. Note that she doesn’t say, ask someone to repot you. It’s a thing you have to do on your own, albeit with help, most times.
I’m feeling might root bound lately myself. The pot I’ve been in for the last seven years is feeling too tight. There’s no room for growth, and I’m constricted.
Noticing that it’s time to repot one’s self (again) is simultaneously terrifying and invigorating. No one who’s ever changed jobs or careers or partners or towns is a stranger to that feeling: standing on the event horizon of an exciting new start, terrified to step out into it. I’m at the tug-of-war stage of repotting just now (I’ve done this several times as an adult, I’m starting to see the patterns). I know my current gig isn’t doing it for me anymore in terms of allowing me to stretch in productive, growth-fostering ways-but it’s steady. In particular, the paycheck is steady, and that’s a major consideration at midlife.
So, how to decide when and where to plant myself next? Jean Baker-Miller, who was always decades ahead of her time (her “New Psychology of Women”, written in the 1970s, is still revolutionary) is helpful with questions of repotting. While Dr. Miller intended her list of 5 good things to be an evaluation tool for interpersonal relationships, I find that it works for careers as well. Her 5 good things are: increased creativity, increased clarity, increased self-worth, desire for more (in her case, relationships, in mine, projects related to a career position), and increased zest or energy.
When I think about my current gig as a graduate school professor, I find that I see it now as energy-zapping, ego-deflating, and generally something I need a break from, rather than something I want to do more of. Seven years ago, when I finished my PhD and began my first job as a professor, I felt the five good things keenly. I felt creative about my teaching strategies and ideas for curricular changes, I felt good about myself based on my new status as a professor, I felt that I’d have time to do the things most central to my mission in this life: advocate on behalf of children and women, write about those issues, and help younger people learn to be effective therapists. Although there were the usual ups and downs; stupid meetings, stupid decisions by pointy-headed administrators, and difficult co-workers, the balance sheet still came out in the positive- until recently.
Now when I look at JBM’s five good things and think about my work, I get frustrated and angry. I don’t have those things at work anymore. We’ve had some big personnel changes in the leadership of the university over the years, and the cumulative impact is that my responsibilities for record keeping and nose counting keep climbing, while at the same time, I matter less and less to the institution and loose my creative freedom a tick at a time.
This slide in balance hasn’t been particularly dramatic. I imagine it’s the same for most workers in organizations at different times. Day by day, my sense of mission and accomplishment has shrunk, while my sense of being forced into a too-small pot has increased. It’s now time to find a new pot.
During the next year or so of transition, I know I need to refocus on my overall mission for this life. I need to stretch creatively and loose 99% of the administrivia in my life. That much is abundantly clear. I’m still working on the details, which means I need to spend a lot more time doing creative thinking and processing (I LOVE the new adult coloring books by Lacy Mucklow & Angela Porter- they’re perfect for focusing thoughts) and talking to folks in the new line of work where I’m planning to plant myself.
If you’re in a similar situation, I encourage you to use JBM’s list of good things. If your current gig isn’t meeting those, what are your options? Can you make enough changes in your work setting to make a difference in the goodness? If not, what’s your ideal pot? If you don’t yet have a clear overall mission for your time in this life, now is as good a time as any to meditate on that and start forming ideas about what shape of container would best support your progress towards those dreams. And a bit of gardening advice- rootbound plants don’t bloom.
One of the great joys of being a professor in a graduate program is watching as young adults grow into creative professionals from being ex-college-students. Every fall, we welcome a group of twelve or so young people, most of whom graduated from their undergraduate programs mere months prior, to campus. Over the next two years, we do the sometimes difficult work of molding them into capable, responsible, and confident beginning therapists. When they leave after graduation, most of them go on to lead rewarding, full, and pro-social lives.
The two years between the arrival of newly-minted B.A. holders and the departure of newly-minted M.S. holders can be tough on everyone involved. Learning to be a competent therapist isn’t easy. The content material; diagnostic categories, pharmacology, neuroscience, counseling skills, theories, and techniques can be overwhelming. Learning to make meaningful connections with total strangers who have lives very different from your own can be exhausting. Developing an identity as both an adult and a professional can be the most difficult aspect of the entire process, especially for 23 year old students whose parents don’t identify as professionals.
The notion of professional identity has been belabored for years in the counseling literature. How do you “be” a counselor? How, if at all, is that person different from who you are at home or with friends? How do you put on this new identity without loosing sight of your former self? Students can struggle mightily with all of these issues, and as much as faculty and supervisors want to help them, it’s a battle each person must face on his or her own.
An interesting cultural turn has recently made this struggle more difficult and less likely to resolve by the time the students leave us. Their parents are now jumping into the graduate program, sometimes at the invitation of the student, but just as often not. Comedians and pundits have talked for years about the silliness of millennial parents over parenting their children to the point of the absurd. Children are no longer left alone to explore the outdoors, even in safe neighborhoods. Parents go to high school dances. They go on graduation trips. They heckle college professors who “give” their child a B or lower.
And now they’re coming to graduate school.
I’ve heard from colleagues around the U.S. that they’re now being contacted by the parents of students about a range of issues, from admissions to internship placement to graduation requirements. Last week, I had my first experience with a parent of a graduate student interfering in the student’s educational experience. I was stunned, to say the least.
And now I’m sad, mostly for the student. The early twenties aren’t easy for most people who are making big transitions from a late adolescent stage, which is drastically extended in modern culture by the university experience, and early adulthood. At the point in their lives when young people most need to wrestle with issues related to independence, freedom (and it’s twin, responsibility), and adult identity, parents are figuratively putting their feet in the doors of development, halting or delaying the process of maturation immeasurably.
I am glad this student’s parents love him/her and are supportive of the journey of higher education. I wonder if they realize that without allowing any struggle at all on the part of the student, they are effectively retarding his/her transition into adulthood. I’m hoping that the parents will learn to allow the child to work through the difficult passages of life with much less interference in the future; I can’t imagine mom or dad calling the boss about a workplace issue, but I guess it’s very possible in the current climate.
It’s my own generation of parents that are crippling their children by eliminating rehearsal for adulthood by removing all obstacles. And it’s us who will have to live with the way we’ve so poorly tended our duties. I’m left hoping not to have to talk to the parents of my doctor before s/he will give me my pills in the old lady’s home.
It’s our mess, X’ers. We need to fix it before it ruins us all.
In the past week, my family lost two Grande Dames, the likes of whom we shall never see again. They were sisters. The elder died unexpectedly, the younger faded out after a long period of debilitating illnesses. Loosing one of them would have been tough, loosing them both almost simultaneously can only be described as shocking. Their relatives joked that the younger sister was always afraid of being upstaged by the elder. so she had to go out at the same time just to have a nicer funeral- that actually might be truthful in some way.
While I was travelling to and from and around the two funerals (both in a small town down south, where my people have lived for many generations) I was struck by the feeling of being watched, followed, seen by unseen eyes. It is quite likely that this feeling was a by-product of stress (the air journey was awful, delays and changes galore) and sadness. However, I think the core of it is more opaque and dense than simple stress.
I’ve made the choice to do as many Americans before me have done; I’ve gone west (and east, and north, and south at various times) to find my fortune. I’ve left home, answered what Joe Campbell referred to as the hero’s call, packed up my knapsack, and gone. Most of the time, this feels right and as it should be. I can’t imagine how restricted and confined I’d feel if I still lived in the town where I grew up. It’s a perfectly good town, but the world is huge, and I aim to see most of it.
It’s a good thing I have the wanderlust- it’s nearly impossible to be an academic and stay put. Higher education demands mobility, at least early on in an academic career. Most professors are not-from-around-here. The idea behind that is to inhibit intellectual inbreeding, which is important when designing universities. You really don’t want all of the professors at State U to be from that state.You’d have a very limited view of life that way.
On the other hand, having all these islands of outlanders sprinkled around the country makes from some odd conglomerations of folks. College towns, and colleges inside of other towns, are often communities of outsiders and rootless wanderers. Many have come with or created families and have stayed in one place quite some time, but they’re (we’re) still not OF the place. Many times, professors pile up together like rats on a raft to make their own little rootless floating communities of chance and location.
I don’t often think of the place where I live now as a raft and myself as a rat on it, but when I go home for real, it does strike me that although I’m not around much anymore, I do still have long sucker roots that go back into the soil of that little southern town.
I am very much aware that my situation is far from unique. Black folks left the south in their hundreds after the Civil War, and again after WWII to seek better jobs up north. White folks did, too. Refugees are everywhere around the globe. People move all the time just because.
However, since this is my one life, it does strike me as a big deal that I live in one place, but am bound to another. I do not believe I’d ever live there again, nor do I want to. I’m fine where I am, and I’ll probably move a few more times to places that interest me or offer opportunities.
I am mindful of the ghosts. There are ghosts that do a fair job of haunting me every time I return to that town. Ghosts of people and events that shaped my life in a million big and small ways. Most of them are friendly and welcome. Some, of course, strike up a chorus of ache and grief for the missing of the people and times that were then and aren’t now.
When I come back here, mostly the ghosts settle down. I don’t have the stinging feeling of acute loss and memory and separation much. Ghosts do fade a bit, but they don’t ever wholly disappear. If I’m quiet for a while, I begin to feel them at the edges of my consciousness, just hanging out, reminding me that things are different now. And although that’s expected in a life of any length at all, it does pull at me from time to time and I wonder how many more ghosts are ahead, how many more I can live alongside peacefully.
I’m not entirely sure how to manage all of them, some days. That is a work in progress, one I imagine everyone has to master at some point or another. For now, I’m just trying to keep them peaceable and placated so I can get on with the present. We’ll see how that goes.
One of the Big Issues in psychotherapy is, and has been for ages, whether the common factors (empathy, trust, the therapeutic relationship) or specific ingredients (the techniques) are more important to helping clients get better. This argument rages on, especially in training programs. We have limited time with our students to prepare them to go out into the world and make it all better for everyone (which is not much of an exaggeration in how most of us see our mission). So, how best to spend our precious semester hours: focusing teaching on the common factors or the specific ingredients?
If research funding is any sort of barometer of importance (and I’m not sure it is), you’d have to conclude that specific ingredients are where it’s at- sorry, I am pathologically incapable of ending a sentence with “at”, so here’s a useless clause. Almost all of the funding coming out of the big federal programs at NIMH, SAMHSA, and NIH are targeted at finding out what, specifically, works for all sorts of people and their problems. Some of the big pushes are aimed at developing multi-modal programs, where, for example, you might have medication management alongside psychotherapy and job skills training for addicts. The programs aimed at research on therapy itself, however, tend to focus on the specific: determining if cognitive-behavioral therapy works for people with eating disorders, finding new diagnostic indicators for PTSD, deciding how long a person with depression needs to be in cognitive-behavioral therapy to get back to work, etc. All of the big federal agencies fund big studies with the hope of finding big answers to big questions, and their work is extremely important.
The findings from the studies funded by the big agencies, and private entities, often drive what insurance companies and Medicaid/Medicare will reimburse providers for providing. The idea, called “evidence-based practice” sounds like solid common sense: they’ll only pay you to do things that research tells us actually works. It’s supposed, I guess, to keep therapists from waving feathers around and chanting and getting Blue Cross to pay for it. I’m all for effective treatment, as long as that’s really what we’re looking for in the research.
Here’s the rub: all of the big studies funded by the big agencies with big grants, which are the bases for the guidelines for reimbursement, look at the small picture- the specific ingredients. And guess what? We’ve known for at least two decades now that the specific ingredients aren’t as important as the common factors in treating clients effectively.
There were a couple of Very Important meta-studies in the 1990’s (Wampold comes to mind) that pretty clearly showed that it matters a lot less what you do in therapy than it does how you do it. Of course, because all endeavors must have critics, the idea that how trumps what has its detractors. Most often, they claim that common factors, which are squishy feelings, can’t be said to be more important than “medical” interventions, like behavior charting and thought stopping techniques. The medical-model side of the house, which often controls the federal funding apparatus, seem to think it unthinkable that the major mover in therapy is the relationship.
I imagine there are a couple of reasons that common factors theory isn’t taken as seriously as it might be. One reason is the squishy-feelings aspect of the common factors themselves. How do you “empirically” measure such things as empathy, insight, clinical judgment, and connection (I have empirically in quotes because I don’t believe true empiricism is possible in therapy research, but that’s a blog for another day)? It’s far more simple to measure how depressed or anxious a person getting Treatment A is than his neighbor in Treatment B than to devise a way to measure how Therapist A connects or doesn’t with Client B versus Client C. The second, more insidious, and I imagine, honest, reason for the continuing popularity of specific ingredients theory is the basic struggle between the chalice and the blade, or the feminine side of healing being rejected by the more masculine side.
It’s not a popular (or possibly, wise) thing to do to say that our whole Western medical model, especially in psychotherapy, may be predicated on the repression of the feminine. It’s also not really where I was planning to go with this essay when I started writing it, but I think at this point, leaving aside the obvious conflict between empiricism and feminism would be cowardly of me.
I don’t have any solution for the common factors vs. specific ingredients divide, but I think it bears more investigation, and probably with a bit of irony and a slightly jaundiced eye.
As for where I’m leaving off in regards to how to focus time with students of psychotherapy, I leave that to the recently departed genius Miller Williams, an excerpt from the magnificent poem, “The Associate Professor Delivers an Exhortation to his Failing Student”.
If one Sunday morning they should ask you
the only thing that matters after all,
tell them the only thing you know is true.
Tell them that failing is an act of love,
because like sin,
it is the commonality within.
How failing together we shall finally pass.