Entering the Behavioral Health Field

A Guide for New Clinicians

Diane Suffridge

• Editorial: Routledge
• Año: 2016
• ISBN:
  9781317287100
• Edición: 1
• Categoría: Psychologie
• Categoría: Bildung in Psychologie

This text provides new clinicians with an overview of the tasks involved in behavioral health treatment as it is practiced in community-based training organizations. The text's specific focus is on the application of theoretical and academic knowledge to clinical work as a psychotherapist or case manager, with a case example that follows treatment from the first session through termination. It contains an overview of all aspects of treatment that are required in these organizations, which are the primary settings for practicum, internship, and post-graduate training.

1 Personal Preparation

DOI: 10.4324/9781315643809-2

(Note: This chapter will use the male pronoun for supervisor, clinician, and client.)

In the behavioral health field, the clinician is an instrument of hope, change, and healing. Therefore, it is essential that we develop self-awareness and self-reflection in order to increase our capacity to be effective instruments. Personal growth and development are an integral part of clinical training and often require that we make changes in familiar parts of ourselves and some of our automatic reactions. This growth is often uncomfortable and even painful, but rewards come from increased emotional strength and flexibility. I describe some of the relationships between individual identity and professional identity as a clinician. I recommend returning to this chapter as you progress in your training, so you can recognize the growth you have made.

Personal Vulnerability and Growth

Motivations for Becoming a Clinician

You probably decided to train as a behavioral health clinician for many reasons: some you are aware of and some you may only discover in the course of clinical training and practice. One commonality for most of us, including myself, is that we enter the field with a desire, often primarily unconscious, to resolve issues that originated in our relationships early in life. We may have adopted a caretaking style toward others because it was rewarded or because we felt comfortable in that role. Perhaps we weren’t cared for in important ways and we now identify deeply with others who are asking for help. For some of us, relationships carry such a danger of rejection and disappointment that engaging with others in a role that is structured and limited allows us to meet our own needs for intimacy without feeling exposed and vulnerable. We also may have had a role model—parent, therapist, mentor, teacher—who we wish to emulate.

In addition to these deeply personal, partially hidden motivations, we generally make the decision to become a psychotherapist, counselor, or social worker based on experiences that give us a taste of what it would be like to be a behavioral health clinician. We may have done rewarding volunteer work or counseled friends successfully or become fascinated with the workings of the human psyche, and we long to learn more. As expected, we find rewards and gratification in working as a professional clinician (McWilliams, 2004).

Unexpected emotions. What most of us do not expect is that this work will lead us to feel emotions, both familiar and alien, that test our inner strength and lead us to doubt our ability to withstand the flood of suffering to which we open ourselves in our clinical work. These emotions are often discordant with our general view of ourselves as well as our view of what a clinician does or should feel. We expect to feel patient, understanding, caring, and valued. We don’t expect to feel angry, disgusted, helpless, disoriented, impatient, or worthless but, like most clinicians, I have experienced all of these emotional reactions at different times. These often disturbing reactions to our clients can help us understand ourselves and those who come to us for help, but at the same time they challenge our emotional equilibrium.

Support for Personal Growth

As a beginning clinician, you are about to embark on a journey of personal and professional growth. Your emotional reactions on this journey may surprise you with their intensity and unpredictability. I recommend using a variety of methods to develop and strengthen your capacity for self-awareness and self-reflection early in your professional training. The following methods have been especially helpful to me and colleagues:

• Personal psychotherapy,
• Mindfulness practices, and
• Supportive relationships with peers.

Personal psychotherapy is required by many training programs, but it is often difficult to find both the time and money for psychotherapy during your training. You may be paying for graduate school, working in clinical training positions for little or no pay, and juggling all of this with family life and other paid work. However, investing in your personal and professional well-being by seeking personal psychotherapy will generate benefits throughout the training process and beyond. It can help you

• Understand the conscious and unconscious motivations that led you to enter clinical training,
• Increase your self-awareness, and
• Manage the intense and distressing feelings that arise in your work.

Many experienced professional psychotherapists set aside a few hours in their schedule for working with clients at a reduced fee, and they are usually particularly interested in working with new clinicians. Help in finding a therapist is often available from professors or the office of training in academic programs and from supervisors in clinical training programs.

Mindfulness practices increase our ability to be open to inner experience without making judgments or rushing into action. Building a repertoire of rituals and skills to help you find calm in the midst of emotional upheaval, both yours and the client’s, is a critical part of becoming a professional clinician. Although a formal practice of meditation is one way to cultivate this calm, there are many other ways to incorporate mindfulness practices in your daily or weekly routine (Hanh, 2009; Siegel, 2011).

Supportive relationships with peers who are at a similar stage of training also support the growth that occurs during clinical training. Friends and life partners can offer understanding and caring, but there is a unique empathic bond between clinicians who face the overwhelming emotions and feelings of responsibility inherent in this work. I suggest you seek out peers who are willing to share openly and to listen while not attempting to advise you or solve your problems. It may take time to find people whose personality and interpersonal or therapeutic style are a good match for yours, so be persistent. I recommend attending a support or process group for clinicians in training if one is available at your training site. This could be a peer group or a group led by someone who does not have an administrative or evaluative role in the training program. Talk with your peers about coming together for mutual support if your agency doesn’t offer a formal group, and let a supervisor or administrator know you are doing so, in order to eliminate the appearance of secrecy and to raise their awareness about your needs.

Transference and Countertransference

Emotions Present in Clinicians and Clients

I have introduced you to some of the emotions that clinicians feel when they sit with clients who are in distress. These emotions can be comfortable, like patience and understanding, or uncomfortable, like anger, fear, hopelessness, and self-doubt. On the clients’ side, they may enter treatment with emotions related to depression and anxiety, have difficulty managing the strong emotions that are related to their life circumstances, and come to treatment feeling discouraged about getting the help they need. The degree of healing that takes place in the therapeutic relationship is directly related to the strength and nature of these emotions.

Definition of Terms

Freud used the terms transference and countertransference to describe the intensely powerful emotions that arise between analyst or therapist and patient or client (McWilliams, 2004). Transference, or the set of patient reactions to the analyst as though the analyst were a past attachment object, was initially viewed as an obstacle to analysis but came to be viewed as necessary for the resolution of past conflicts in attachment relationships. Similarly, countertransference, or the set of analyst reactions to the patient that go beyond the professional desire to be helpful, was viewed as potentially problematic. Contemporary psychoanalytic theory has moved toward a relational perspective in which the interpersonal experiences of both analyst and patient are considered active in the therapeutic relationship. Transference and countertransference are seen as inevitable and necessary in the healing process (McWilliams, 2004).

Currently, the term countertransference is used by practitioners of psychodynamic and other theoretical perspectives to describe the clinician’s emotional response and reactions to the client. Some practitioners limit the term countertransference to the clinician’s unresolved conflicts while others include all responses that arise in relation to the client (Hayes, Gelso, & Hummel, 2011).

Using Countertransference Responses

I recommend identifying and reflecting on your countertransference responses to clients because your responses provide information about the client and yourself. Specifically, countertransference is

• A source of information about the client’s inner world of internalized relationships, and
• A way to deepen your understanding of your interpersonal patterns and responses.

If you work in a training setting that uses psychodynamic theory as its foundation, your supervisors will probably encourage you to identify and discuss your countertransference. This will help you to use your emotional responses to inform the treatment and develop greater skill in working with difficult interpersonal patterns. Supervisors from other theoretical perspectives may also inquire about countertransference as a way to help you identify your emotional response and your contribution to the quality of your therapeutic relationships with clients.

Cultural Identities

The cultural influences that have shaped your sense of self are part of your therapeutic presence. You may have greater awareness of some aspects of your cultural background than of others, and this may be especially true if there are ways in which your background places you outside the dominant cultural group. Also, your feelings about different aspects of your cultural background probably vary. For example, you may feel confident about being a Jewish man and embarrassed that you speak with an accent due to immigrating to the United States as a teenager. Your experiences with others who are similar to and different from you have shaped your understanding of and comfort in interpersonal interactions, and you bring all of this self-awareness and prior experience into your relationship with your clients.

There are many aspects of cultural identity, which are more or less salient in different social contexts. One helpful framework for examining these multiple influences (Hays, 2008) uses the acronym ADDRESSING.

• Age and generational influences
• Developmental disabilities
• Disabilities acquired later in life
• Religion and spiritual orientation
• Ethnic and racial identity
• Socioeconomic status
• Sexual orientation
• Indigenous heritage
• National origin
• Gender including gender identity

In examining your cultural identities, one or more of these identities may feel central to your sense of self and others unimportant. Often, the features of your cultural identity that match those of the dominant cultural group seem less significant because their impact on your development is less obvious. Being part of the dominant group is associated with privilege: a set of unearned benefits and advantages (Dressel, Kerr & Stevens, 2010). If you were born and raised in the United States and are Caucasian, middle class, male, and/or heterosexual, you may not have spent much time reflecting on how those factors influenced your personality, beliefs, values, and interpersonal style. I encourage you to do so as part of your clinical preparation in order to become aware of assumptions and cultural blind spots that may be present for you.

Most graduate school programs include academic courses to increase awareness of the influence of culture. You will find these courses to be a beginning step in developing cultural sensitivity and knowledge. You may also need to seek out other experiential opportunities to gain self-understanding of the impact of cultural experiences on your personal and professional identity (Cornish, Schreier, Nadkarni, Metzger, & Rodolfa, 2010).

Professional Boundaries

Definition

The concept of professional boundaries may be unfamiliar to you, unless you have prior experience in a behavioral health setting, a social service agency, or another service profession. The term professional boundaries refers to the structure and limits that are placed on the contact between clinician and client in order to ensure that the focus of their time together is on the client’s needs and welfare and that the intense feelings that can arise in clinical work are managed differently than they are in other relationships.

Reasons for Professional Boundaries

Maintaining professional boundaries is crucial, in order for treatment to be helpful to the client in managing his difficulties. Professional ethics codes require that the client’s welfare remain the clinician’s primary concern, and this is only possible when the safety and security of both client and clinician are ensured by the presence of professional boundaries in their relationship (American Association for Marriage and Family Therapy [AAMFT], 2001; American Psychological Association [APA] 2002; Barnett, 2011; National Association of Social Workers [NASW], 2008).

In addition to this ethical requirement, maintaining profess...