Letters to a Young Student of Psychology
I was recently asked by a young student in psychology to answer questions for a report she was writing. The report was on working with patients who are experiencing problems that hit close to home. Below are both her questions and my answers. Because I graduated from my last clinical training year today, I thought it would be a nice day to publish this post.
Dear Young Psychology Student,
In the text below, I've done my best to fully answer your questions about my experience training as a psychologist.
Have you worked with school-aged children and adolescents? Briefly explain in what capacity you have worked with this population. What were the successes? What were the challenges?
Yes, I am at the very end of my 6th year in a clinical psychology PhD program and I just completed internship at North Shore LIJ Hospital (I came directly from my graduation ceremony to this blog, in fact). On internship I carried a caseload of child & adolescent patients; however, my prior training was largely with adults.
For the first six months at North Shore LIJ, I carried a caseload on the locked adolescent inpatient unit at the hospital. There I treated patients with first-break psychosis, recent suicide attempts, or physically violent behaviors. During the second six months of my position, I worked with patients medically at risk secondary to severe eating disorders. My patients were either hospitalized on a medical inpatient unit or attending the eating disorders day program, which is a 8:30am to 5:30pm fully structured hospital program. Additionally, for this entire year, I carried an outpatient caseload.
I conduct only evidence based treatments (EBTs; e.g. cognitive behavioral therapy). So, in terms of successes: when Evidence Based Treatment is being conducted, a lot of symptoms tend to improve. Therefore, I get to see a lot of success. Specifically, I love seeing patients recover from anorexia nervosa. It is consistently amazing to literally see a great deal of progress made over a short period of time. For instance, we typically treat people who start off at risk of dying from being so underweight until they gain upwards of 15-20 pounds. You can see that progress. At LIJ, we have a very strict refeeding program that promotes both physical and mental health.
The biggest challenges for me are:
A) Working with parents who do not accept diagnoses. Many times parents of children with certain disorders (e.g. autism or eating disorders) refuse to accept the diagnosis. This can be particularly frustrating when this prevents the child from receiving services during a critical phase of their development or illness. If the parent doesn't come to accept a diagnosis in time, that child runs the risk of being severely affected for his / her entire life by the parent's lack of acceptance.
B) Calling child protective services (CPS) under some conditions. In some extreme circumstances, CPS must be legally called when parents are neither abusing nor neglecting their children. Parents may simply not be equipped to deal with their child’s emotional needs. For instance, if your patient premeditatively stabs a sibling and threatens to do it again, a CPS call may be made even if the parents are "good" parents. In a case like this, the issue is that parents are unable to control risk of one of their children seriously injuring / killing another of their children. If the parent does not take the appropriate measures to ensure the safety of the victimized child by making (sometimes expensive) accommodations for the violent child, CPS may be called. It's very difficult to be in situations like these. Although in my experience only very reasonable accommodations are requested, in order for parents to follow through, they must emotionally accept that one of their children is a serious threat. A well-intentioned parent may have the "he won't intentionally stab his sister again... it will be ok" type of mindset. Of course, this is unacceptable when a patient has clearly expressed murderous intent.
Question 2: Have you worked with a child that has lost a parent? What have you found challenging? What have you found to be helpful for the client?
I haven't worked with a child grieving the death of a parent; however, I have worked with patients grieving the loss of a parent. Specifically, patients in foster care grieve the loss of their parent in a primary care giving roll. Some parents clearly demonstrated neglectful / abusive behavior, while some parents were not able to protect others from the violent behavior of the patient.
Challenging: It pulls at my heart strings when patients grieving the loss of a parent ask questions about the future. The question when the child is removed from the home is always “what is going to happen to me?” and I can’t really answer those questions. While some foster homes and residential settings are wonderful, others are not. When working with patients in the hospital, I have no idea about the quality of the home where they would be next. That can be tough.
Helpful: It is helpful not to intervene when a patient is actively grieving. While on internship, I have had to break very difficult news to patients and have been present at the time the very instant the grieving process started. In that specific moment, my job isn’t to relate to the patients or actively try and make them feel better. My job is just sit there with the person and be as fully present to them as possible. In instances like this, only when the person truly wants to be alone, do you leave them alone.
In terms of advice, I would say this: knowing when grieving ends and a disorder begins is imperative. Unfortunately, there are no easy rules to follow about this. You can't say something like "oh, after two months, this child should be over the death of their parent." You can, however, assess whether or not the person is emotionally avoidant. Grieving implies that the person is actually experiencing the emotion of sadness that naturally accompanies loss. If the person is doing things like drugs etc to avoid feelings of grief, we have a problem. Once you figure out if/how the patient is avoiding, then rule is this: if the person is actually experiencing grief, sit with the emotion; however, if there is dysfunction secondary to avoidance, then intervene. I think the ability to skillfully assess and intervene will naturally come with experience. There's a whole book to write about this.
Is there a population that you see yourself in or relate to on an emotional level? What is that like? What has helped you maintain emotional distance? What has helped you to not “take the work home?”
I have thought about this a lot, but I’ve never actually talked to anyone about it. So here we go. I think that if you really undergo a lot of self-examination over many years across many different experiences, you have the ability to remember even very mild emotional reactions, inclinations, and urges. If you’re aware of the wide breadth of your own experience, it can be very easy to relate to patients, at least on some level. In short, understanding yourself helps you understand others. Because of this, I have found that I relate to every patient about something on an emotional level (to varying degrees of course).
There have been a few times where I really see myself in a patient. When this happens, it forces me to look at decisions I have made. In these circumstances, I internally relate as much as I can to the patient and use genuine sympathy and understanding to build the relationship. And with a strong relationship, we can facilitate adaptive change together.
I didn’t think it is necessary - or even helpful - to maintain emotional distance. I don't wall myself off from experiencing my own emotions because that usually ends poorly. It is helpful to use my emotions in session. That isn't to say though, that a therapist shouldn't maintain an objective lens. A good CBT therapist will know how and when to think rationally. In fact, it is wholly possible to think rationally about a scenario while also experiencing real emotion.
In a way, you should take your work home. Of course it isn't helpful to be overly involved with your patient's lives, but if a patient's experience was emotionally triggering for you, take home your own emotion about your own life. Process that.
Do you have any advice for me?
I know that the reason why you're asking these questions, Young Student in Psychology, is that you lost a parent and you're worried that having a patient with a similar experience will be too much. So listen, if you’re working with a patient who lost a parent and it triggers sadness about your own loss, sit with that. Accept it. Pay attention to it. Ignoring this opportunity for your own emotional growth would only be hurting you. You are going to have strong emotions and that is ok. In this field, we have the privilege of helping other people through difficult emotions, which also happen to provide us with special opportunities for insight into ourselves.
In terms of advice, I would say this: be genuine and don’t avoid. If something upsets you, obviously don’t make the session about your problems, but allow yourself to feel emotions about the patient’s pain in session and express your own pain when you get home. Over time, exposing yourself to what you’re afraid of or emotionally sensitive to will make you stronger than you can anticipate. Although the hole in your life caused by the death of a parent will never close, it will become easier to manage your emotions about this. The more opportunities you give yourself to experience those emotions, the better therapist you will become and the stronger you will be. Make mistakes and put yourself in situations you are not sure you can handle.