Institute for Clinical Social Work
Therapist Experiences Working with Parents in Child-Welfare Cases
A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy
By
Bonnie Holiday
Chicago, Illinois March 2017
Abstract This grounded-theory study explored the experiences of 16 therapists in the Midwest, who worked clinically with parents mandated to treatment through the child-welfare system. All participants talked about their experiences working with this client population and the challenges and rewards they encountered. Major findings derived from the results of 16 interviews, one with each participant. Participants discussed feeling alone in their work, due to a tendency in America to deny the magnitude of certain problems, including: 1. Child abuse 2. Child neglect 3. Poverty 4. Domestic violence 5. Sexual abuse Participants explored the difficulty of their work and its capacity to evoke numerous emotions. The triadic nature of the clinical work involving client, therapist, and the mandating agency can cause interference in the clinical encounter. Transference and countertransference left untended can be another source of interference. The difficulty of the work requires professionals to stay in tune with themselves, avoiding vicarious trauma or burnout. Despite their difficulties and challenges, most participants had adequate support, good self-care regimes, and a passion for helping―all of which made the work mostly rewarding.
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Acknowledgments
I want to thank my dissertation committee for their commitment to me and their patience as I completed this study. The members are Dennis McCaughan, Carol Ganzer, and readers Denise Duval Tsioles and Michelle Sweet. I especially want to thank James Lampe, my Chair, for seeing me through to the end, and for providing encouragement all along the way. Thank you all for your passion for teaching and mentoring. The world is a better place because of you. BH
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Table of Contents
Page Abstract..............................................................................................................................ii Acknowledgments…………………………………………………………........……….iii List of Tables..……………………………………………………………….................viii Chapter I.Introduction…………………………………………………..…………......................1 General Statement of Purpose Significance of the Study for Clinical Social Work Formulation of the Problem Foster Care Statistics II.Statement of Relevant Knowledge or Theory and Review of Significant Literature………………………………………………….……………….......................8 Introduction Motivation for Change Therapeutic Alliance Ethical Challenges Confidentiality Oppressed Groups Disproportionately Court-Ordered to Treatment Insufficient Training for Working with Mandated Clients Countertransference Contemporary Theory Theoretical and Conceptual Framework of This Study
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Table of Contents—Continued Chapter
III.
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Methodology…………………………………………………………..................….32 Type of Study and Design Scope of Study, Setting, Population and Sampling Sources, and Nature of Data Data Collection Methods and Instruments Procedures for Data Analysis Ethical Considerations Limitations of the Research Plan
IV.
Introduction to Results………………………………………………..............……46 Member Checking The Participants The Four Major Themes
V.
The Fabric of American Life No One Wants to Talk About……….............……53 Support of Others: Creating the Capacity to Maintain Empathic Engagement Self-Care Working with the System
VI.
The Work Is Hard and Evokes a Variety of Feelings………………….................67 Introduction Hope Anxious Sad Traumatized Conflicted Angry Inadequate Powerless Disappointing Worry Frustration Heartbreaking of Disheartening Heavy Guilty Stressful
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Table of Contents—Continued Chapter VII.
Page
Interference in the Clinical Encounter…………................………………………87 Four “People” in the Room Transference and Countertransference
VIII.
The Personal Toll of the Work and How to Manage It………...............……….102 Occupational Difficulties Managing Feelings Required
IX.
Findings and Implications………………………………………...............………128 Overview Brief Description of Findings Clinical Implications Definitions: Secondary Traumatic Stress, Vicarious Trauma, Compassion Fatigue, and Burnout The Importance of Empathic Engagement despite the Hazards Managing the Work Summary of Implications Limitations of Qualitative Research Implications for Clinical Practice Implications for Policy Future Research Final Thoughts
Appendices A.
Phone Script………………………………………………................………175
B.
Participant Consent Form…………………………………….............…….178
C.
Semi-Structured Interview Questions………………………….............…...183
D.
References…………………………………………………….............………185
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List of Tables
Table 1.
Page Participant Data………………………………..………………………………49
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CHAPTER I
Introduction General Statement of Purpose The purpose of this grounded-theory study was to understand the experiences of clinical social workers working with parents who have lost custody, or are threatened with loss of custody, of their children. All participants volunteered to discuss their clinical experiences working with this client population. At present, more than 500,000 children reside in out-of-home placement (AFCARS, 2013). The parents of these children are often referred for therapy by the state’s child-protection and foster-care caseworkers. The experiences of these social workers in the clinical setting are the subject of this research.
Significance of the Study for Clinical Social Work Clinical social workers are called upon to provide treatment for parents seeking to regain or maintain custody of their children. These parents present a multitude of complex, longstanding problems that require clinical attention. Court mandates and the stresses that these clients present can make the work of the clinical social worker discouraging at best. Neil Altman expresses it well in his book, The Analyst in the Inner City:
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Life in the inner city entails a greater burden of stress, loss, and trauma than life in working-class-and-up communities. These conditions predispose to psychopathology (Brown and Harris, 1978) and form part of what is enacted and experienced in the transference and countertransference when one works psychoanalytically with inner-city patients. (p. 1) Although not all parents who lose custody of their children reside in cities, they often do not have the resources of “working-class-and-up community� clients. Many clinical social workers work with parents who have lost or are threatened with loss of custody of their children. However, little is written about the dynamics of this clinical triad, which includes the client, clinical social worker, and the state (or mandating agency). This study will contribute to the body of knowledge regarding clinical social work with families involved in the child-protection or foster-care systems who acquiesce to treatment with a therapist.
Formulation of the Problem Parents who have lost or are threatened with loss of custody of their children involuntarily present the social worker with clinical challenges unique to this client population. Their presence in the clinical room is generally mandated under threat of termination of parental rights. Often the issues they present are complicated and longstanding. The mandating organization usually requires the therapist to report progress on clinical goals and uses those reports in court where decisions are made regarding custody. The triad of clinical social worker, client, and mandating agency provides a unique situation and can be fraught with difficulties.
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The objective of this study is to explore the issues above, specifically through the view of the clinical social worker. Through the collection and analysis of data, a theory will be developed that will fill a void in existing literature regarding the experiences of this population of clinical social workers. In addition, it will aid the provision of care for their clients. When people are court-mandated to treatment, it implies they would not seek services on their own. Although psychiatric services might be mandated for a multitude of reasons, the focus here will be on parents at risk of losing child custody, or who have already lost custody and are mandated by the court to engage in mental-health services. States are required to report data regarding child abuse and neglect. In 2012, 3.4 million reports of abuse and neglect were made to child-protection agencies across the country. With 45 states reporting more than 2 million of the 3.4 million total, reports were “screened-in� for investigation. Of the reports investigated, 678,047 were substantiated. More than 80% of the perpetrators of abuse and neglect were parents of the child (US Department of Health and Human Services Administration for Children and Families, 2012). Child-protection agencies refer these families to a variety of services, which may include individual, family, or group therapy. Data indicates that from September of 2013, 523,616 children were in foster care. Generally, more than 50% of children have a case goal of reunification with parents (Child Welfare Information Gateway, May 2012, p. 1). Parents with children in foster care are often court-mandated to mental-health treatment and educational programs. Parents who perpetrate physical or sexual abuse, or who neglect their children, are often given the opportunity to improve their parenting skills through counseling and classes.
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Additionally, children are often placed in care when their home environments include substance abuse or domestic violence. Court-mandated services are designed to help parents overcome obstacles to providing a safe home for their children. Therapists are called upon to provide services to address the issues presented by this population of clients. “The counselor-client relationship has been conceptualized as a working alliance, founded on trust, openness, genuineness and congruence” (HoneaBoles & Griffin 2001, p. 150). A court mandate profoundly impacts this relationship. Multiple dilemmas occur when dealing with coerced clients. The client experiences the double bind of refusing treatment versus admitting “wrongs” to a therapist aligned with the authorities. The clinician faces the ethical dilemma of respecting the client and working to establish a therapeutic relationship while conspiring with the authorities who might take the client’s children away. (Honea-Boles & Griffin 2001, p.154) This dilemma makes for a clinical experience wrought with emotion for both clinician and client. Common problems to be addressed for clients mandated to treatment include: domestic violence, child abuse, neglect, sexual abuse, and substance abuse. It is generally agreed that most research on mandated clients pertains to substance abuse. In child-abuse and neglect cases, courts seek to rehabilitate instead of punish, thereby making mandated treatment a popular choice for parents whose children reside in foster care or in situations where parents are under threat of losing custody.
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Foster Care Statistics In September of 2013, the U.S. Department of Health and Human Services, Administration for Children and Families reported 399,546 children living in foster care (Administration for Children and Families, 2013). Every state and U.S. jurisdiction has laws governing the termination of parental rights. Most require the local court to provide “clear and convincing” evidence that the parent is “unfit” and that the dissolution of the legal tie is in the best interest of the child (Child Welfare Information Gateway, 2012). Once children have been removed from parental care and custody, involuntary termination of parental rights may be pursued by local authorities if a child is deemed at risk of abuse or neglect if returned to the parental home. Each state has the authority to determine the specific grounds by which an individual is deemed unfit to parent. The Adoption and Safe Families Act (ASFA) of 1997 mandates that states make “reasonable efforts” to reunify children with their parents (Child Welfare Information Gateway, 2015) once they have been removed involuntarily. Caseworkers are given the task of providing the necessary tools to assist families with improving the conditions that brought the children into care. Some services offered to parents may include (a) parenting classes, (b) substance-abuse rehabilitation, and (c) mental health services. The parents of some children in care present with “deeply rooted, long-standing problems” that therapists are called upon to help rectify (Alpert, 2005, p. 364). Parents may suffer from social, psychological, and environmental difficulties, making it a challenge for them to regain custody of their children (Flemons, Liciso & Rebholz, 2010). For family reunification to occur, parents of children in out-of-home placement are often required to engage and “succeed” in some form of individual therapy. Since its
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inception, clinical social-work practice has operated under the assumption that clients engage in services voluntarily. Rules of engagement, assessment, goal setting, and intervention through to termination are all based on this belief (DeJong & Berg, 2001). Parents of children seeking to regain child custody are frequently unwilling participants in the therapeutic process. Court mandates for parents to engage in services make for a unique clinical experience for both client and clinical social worker. For the clinical social worker, the challenge of working with mandated clients begins with their education. Social-work academic departments endeavor to produce competent practitioners ready to face the challenges presented by clients in a variety of settings. Whether consciously or not, clinical social workers operate from a system of personal beliefs, most likely taking hold during the worker’s formal education. Likewise, clients come to the table with their own set of beliefs and expectations (Ghent, 1989). When clinical social workers treat abusive and neglectful parents, both parties embark on a journey into the unknown. Therapists and clients come to the table with their own sets of beliefs and expectations. Clients generally seek relief from the ties that bind them to a system that “controls” their lives. Mandated treatment represents only one of many tasks that must be completed “successfully” to break free from the system. In that regard, therapists engage in a form of coercive treatment with these clients. Therefore, therapists must examine their professional identities. Are they an “enforcer rather than a healer” (Will, 1968, p. 26)? Along with the challenge of engaging an unwilling client, therapists must write reports for review by caseworkers and the court. The practitioner is expected to remedy the problem and document the details of the remedy (Dinkmeyer, 1999, Phillips, 2009).
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Caseworkers use clinical social-worker reports in court to prove “progress,� or lack thereof. Therefore, therapists can find themselves in a quagmire of conflicting challenges when endeavoring to help their clients. The interactions between social worker and client go under the court’s microscope and can mean the difference between a parent permanently losing, or eventually regaining, custody of their children. This added pressure on the client / therapist relationship is present in the therapeutic encounters with this client population, and the related dynamics deserve additional research. This study intends to provide that research.
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CHAPTER II
Statement of Relevant Knowledge or Theory and Review of Significant Literature Introduction This chapter will explore client mandates and the issues they present. Additionally, this chapter will discuss psychoanalytic theory and Relational perspective in terms of its usefulness as a clinical model that considers therapist subjectivity. Clinicians must understand transference and countertransference when working with mandated populations. Therefore, these two dynamics will be discussed through different psychoanalytic lenses. Finally, within the context of broader psychoanalytic conceptualizations, I will review contemporary Relational Theory, which emphasizes the relationship of therapist and client, thereby accounting for the clinician’s subjectivity as part of the clinical process. By reviewing Relational Theory, we will create a context and understanding for the research results in this study.
Motivation for Change Literature on clinical theory and practice suggests that mandated clients are more resistant to treatment than their voluntary counterparts (Snyder & Anderson, 2009). Although some would argue that a motivation to change is required for positive outcomes of treatment, some research suggests that clients can change even when initially resistant
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or unmotivated to engage in treatment (Snyder & Anderson 2009; Burke & Gregoire, 2007; Lehmer 1986). The courts are generally thought to provide the coercion for clients mandated to treatment, but not all mandated clients receive judicial pressure. Family and friends often provide the impetus to seek counseling. No matter the source of coercion, the same dilemmas can present themselves in the clinical encounter, making the work of treating mandated clients challenging for practitioners. “Explicitly examining the context and conditions that propel or compel individuals into treatment seems an important starting point for establishing a therapeutic relationship that can foster and support change” (Burke & Gregoire, 2007, p. 13). A court order to therapy can provide the needed pressure for individuals who might not otherwise seek help. Such orders have the dual advantage of protecting an abused child and outlining the criteria for “therapeutic success” (Lehmer, 1986, p. 16).
Therapeutic Alliance The therapeutic alliance is generally accepted as a significant factor in the clinical relationship for those seeking change in their lives. As Regehr and Antle (1997, p. 304) explained: The therapeutic alliance is generally defined as the observable ability of the social worker and the client to work together in a realistic, collaborative relationship based on mutual liking, trust, respect, and a commitment to the work of counseling (Coady, 1993).
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Involuntary clients provide a challenge for the therapist to establish the connection necessary for successful social work. Lehmer recommends that the therapist remember the “client” is court-ordered, not the therapist. Therefore the “responsibility” to succeed lies with the client (1986, p. 17). Clarifying the roles of all parties involved with the mandated client can enhance the possibility for a therapeutic alliance to develop (Lehmer, 1986; Waldman, 1999). The counselor-client dynamic forms the foundation for “successful therapy” and therefore should be distinguished from other types of helper relationships that involve caseworkers, case managers, and so on (Honea-Boles & Griffin, 2001, p. 150). Burke and Gregoire (2007, p.7) discussed how involuntary clients can be “perceived negatively by practitioners,” and these negative feelings can negatively impact the therapeutic alliance. Clarifying the roles and responsibilities of all parties involved with the mandated client can increase the possibility of a solid therapeutic relationship, and, therefore, more successful outcomes for both therapist and client. Literature has proposed, without exhaustive research, the idea that a quality relationship between provider and client will enhance the possibility for success for those mandated to treatment (Skeem et.al., 2007; Bowen, 2010). The use of empathy is essential in forming a therapeutic alliance. Empathy is the hallmark of therapy services and an essential component of working with the mandated client (Dinkmeyer, 1999; Honea-Boles & Griffin, 2001). Being a good listener and providing the same level of empathy provided to non-mandated clients can be challenging when the client is ordered to treatment. The anger the client feels towards the
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mandating organization will likely be evident in the clinical encounter, complicating the formation of a therapeutic alliance. Building the therapeutic alliance is a significant part of the work conducted by clinical social workers with mandated clients. Some researchers believe it is the most critical component of a successful working relationship (Honea-Boles & Griffin, 2001). When social workers assess mandated clients, they use expert skills to garner information to use in building a working assessment plan. During this phase of treatment, clients may be lulled into thinking that an evaluator is working in their best interest. They may misunderstand the dual relationship of commitment to the client and commitment to the mandating organization. The clinician has an obligation to work in the client’s best interest while at the same time maintaining the broader mandate to guard the safety of children. The client may misunderstand the limits of confidentiality in this clinical situation (Regehr & Antle, 1997). This dilemma will ultimately have an impact on the therapeutic alliance if not handled properly. Research regarding this type of clinical dilemma is currently lacking.
Ethical Challenges Court-ordered therapy has been described as “an ethical minefield” for people working as psychotherapists. Shearer uses the term “therapy as punishment (TAP)” to describe the work of court-ordered counseling, and he lists “confidentiality, dual relationships and informed consent” as issues that therapists must address in their work with mandated clients (2003, p. 8). Others believe the act of mandating a client to treatment provides the needed impetus for individuals to engage in services they might
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not otherwise consider (Lehmer, 1986). Most agree that a clinical encounter with a courtordered client will provide ethical challenges that must be addressed. The power imbalance between client and clinical social worker cannot be ignored when working with mandated clients. A court order may keep a client in therapy, but what transpires during the sessions will determine the quality of engagement. Turney (2012) suggests a relationship-based practice based on three “R’s” (recognition, respect, and reciprocity). Turney points out the potential for an ethical breach when the client rejects attempts by the clinical social worker to help. As the expectation of recognition is reciprocal, either party may experience the refusal or failure of the recognition. So arguably, this may apply as much to practitioners as service users. It is therefore important for practitioners to be aware of this dynamic and to be alert to their own responses to feelings of being ‘mis-recognized’ by antagonistic or unwilling clients. Resistance is clearly difficult to deal with and can be particularly undermining for a practitioner to find that their efforts to engage parents are rebuffed and their good intentions viewed with suspicion or hostility. If not acknowledged, the sense of rejection – of not being recognized for oneself – can have a significant impact and lead to potentially punitive, or equally dismissive, responses on the part of the worker. (Turney 2012, p. 154) The temptation for the clinical social worker to retaliate cannot be ignored. Since a power imbalance is always present when working with mandated clients, the therapist must acknowledge the potential for the abuse of power. There is limited research delving into the ethical challenges of this power imbalance for these types of clinical encounters.
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Although self-determination is a “central tenet of social work ethics” (Regehr & Antle, 1997, p. 300) it is difficult to manage the various ways in which the power discrepancy may arise. Most therapists, from any number of theoretical leanings, would agree the client should have the freedom to choose a therapist and the free will to terminate services or change service providers. For the mandated client, such selfdetermination would risk sanctions from the mandating organization, making it imperative to recognize potential abuses stemming from the power differential. Therapists working with mandated clients find themselves in a dual relationship. Their training and code of ethics requires a “client-first” stance, while at the same time the mandating organization requires loyalty. Mandating organizations often provide payment for service. This makes it especially difficult for a therapist to align with the client when the goals of the mandating organization and the client may be at odds.
Confidentiality For clinical social workers, the mandate to keep clinical sessions confidential is a matter of professional honor. In addition, State laws also require rigid adherence to the mandate. However, in cases where a client has been mandated to treatment by court order, the client’s right to confidentiality is null and void (Lehmer 1986). This situation causes an ethical dilemma for the treating clinician.
Oppressed Groups Disproportionately Court-Ordered to Treatment Special attention should be paid to the fact that minorities and poor individuals are mandated to treatment at greater rates than others (O’Hare, 1996). The problems that
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bring parents into the child-welfare system also keep them from engaging treatment (Kemp, et. al., 2009). Cultural factors can impact parents’ willingness to engage services. Historically, African American children have been overrepresented in the child-welfare system, and mistrust based on past inequities has an impact on present interactions with workers (Kemp et. al, 2009). Intervening with a culturally diverse client population mandated to treatment can provide challenges for even the most seasoned clinician.
Insufficient Training for Working with Mandated Clients Most theories of treatment assume that clients participate voluntarily and are motivated to engage in therapy (De Jong & Berg, 2001). Therefore, most schools of psychotherapy do not provide the type of training needed for clinicians to engage and treat the mandated client (Snyder & Anderson, 2009). This lack of training, combined with complications unique to mandated cases, can leave therapists discouraged, frustrated, and in doubt of their professional skills. If not addressed properly, this type of clinical situation provides a setting ripe for negative outcomes. Without a better understanding of the impact on the subjectivity of the clinician, clinicians venture into this work as if going into a dark room. This study explores issues observed in work with this population from the perspective of the clinician. Schools of social work teach clinical-practice theories that rarely address mandated care. As Shearer points out, “… counseling theories are quite diverse and most theories only vaguely discuss involuntary counseling if they address the practice at all” (2000, p. 153). It is generally agreed that more training is needed for individuals providing clinical services for mandated clients.
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In summary, it is imperative that a more thorough understanding of clinical work with the mandated client from the perspective of the clinician be studied. In particular, defining countertransference and paying close attention to the subjectivity of the clinical social worker is needed to enlighten this aspect of the clinician’s experience in working with a mandated client.
Countertransference Difficult clients present for treatment in all variety of clinical settings. They can be found in private practice or public clinics, hospitals, or small non-profit agencies. Wherever they engage the therapeutic process, they evoke in the clinical social worker a myriad of countertransference reactions. Understanding the psychoanalytic concepts of transference and countertransference assists the clinician working with parents who have lost or are threatened with loss of custody of their children. Freud’s concept of transference emerged in the context of his realization that one could not attempt a cure in isolation from the interpersonal process that evolved around the effort. Not only did Freud find that his process could obstruct the goaloriented effort, but it was his genius to conceive that the process contained within itself the very pathological situation that needed to be addressed in order for a cure to take place. (Altman, 1995, p. 160) Transference and countertransference has been a topic of study since Freud first illuminated the two concepts. Volumes have been written to elucidate their definitions and uses in clinical social work. In its broadest definition, countertransference is what the
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therapist brings to the clinical encounter. In this study of therapist’s reactions to their clients, a thorough understanding of countertransference is necessary. For some, countertransference is pathological and to be avoided. Freud first talked about the idea in a 1910 paper, “The Future Prospects of Psycho-analytic Therapy,” as follows: We have become aware of the ‘counter-transference,’ which arises in him as a result of the patient’s influence on his unconscious feelings, and we are almost inclined to insist that he shall recognize this counter-transference in himself and overcome it.” (Freud, p. 143-144) Freud again talks about countertransference as a hindrance in his 1915 article, “Observations on transference-love.” He cautions his audience to maintain “…neutrality towards the patient, which we have acquired through keeping the counter-transference in check” (Freud, 1915, p. 163). Although there may be different definitions and opinions regarding the usefulness of countertransference, since the beginning of psychoanalysis it has been accepted as existing. In 1919, Ferenczi took issue with the notion that countertransference was an impediment to the analytic process. Contrary to popular thought on counter-transference at the time, he expressed his opinion of the “inevitability of countertransference and of the idea that it is valuable in understanding the patient” (Jacobs, 1999, p. 577). More than 15 years after Freud’s mention of counter-transference as an impediment to the therapeutic process, Ferenczi, Balint, and Sullivan took a different approach and began examining the possibility that countertransference could be useful in the clinical setting. Other theorists would follow, creating a tremendous, cumulative impact on
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prevailing thoughts about countertransference (Teitelbaum, 1991, p. 268). Although countertransference was believed to exist, before these bold theorists presented their ideas for review by colleagues, the dynamic was considered bad and something to stay away from. Adolph Stern believed the therapist brought two types of countertransference to the clinical encounter. The first involved the therapist’s “personal conflicts,” and the second was a reaction to the transference brought by the patient (Jacobs 1999, p. 578). Stern laid some groundwork for others to build the idea that countertransference can be a useful tool in the therapy room if understood and used appropriately (Stern 1924, p. 169). Even Strachey recognized the “mutuality in analysis” (Jacobs 1999, p. 579). He recognized the analyst’s emotional reactions during the analytic process. Although he did not use the word “countertransference,” he explored the concept in his writing. In 1939 Balint and Balint wrote an article called “On transference and countertransference.” In this article, they furthered the notion that the interplay between patient and analyst is always present. “Looked at from this point of view,” the authors wrote, “the analytical situation is a result of an interplay between the patient’s transference and the analyst’s counter-transference, complicated by the reactions released in each by the other’s transference on to him” (Balint & Balint, 1939, p. 228). In “Hate in the Countertransference,” Winnicott cautions that in addition to the patient and his or her psyche, those involved in clinical work “… also must study the nature of the emotional burden which the psychiatrist bears in doing his work” (1949, p.69). Winnicott also believed that countertransference was present in the clinical setting, and
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additionally provided information for therapist use. His article helped to open the study of countertransference as a legitimate, helpful tool in working with patients. In 1950 Paula Heimann wrote a short but powerful article embracing the use of countertransference, in which she stated, “My thesis is that the analyst’s emotional response to his patient within the analytic situation represents one of the most important tools for his work. The analyst’s counter-transference is an instrument of research into the patient’s unconscious” (Heimann, 1950, p. 81). Racker gathered his writings into a book called Transference and Countertransference (1968), in which the author addressed the arduous task of defining countertransference and its uses in the clinical encounter. For Racker, countertransference should be acknowledged and used to further the understanding of the psychological workings of the analysand. Racker stated, “Every transference situation provokes a countertransference situation…” (p.137), therefore implying that analysts must acknowledge and maintain awareness regarding their own countertransference reactions. In 1951, Margaret Little implored her readers to embrace countertransference and not be “afraid.” She believed counter-transference to be “essential” to the work of analysis, saying: Counter-transference is a defence mechanism of a synthetic kind, brought about by the analyst’s unconscious ego, and is easily brought under control of the repetition compulsion; but transference and counter-transference are still further syntheses in that they are products of the combined unconscious work of patient and analyst. (Little, 1951. p. 40)
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Little summarized her position on countertransference by stating, “… in fact it cannot be avoided, it can only be looked out for, controlled to some extent, and perhaps used” (Little 1951, p. 40). Counter-transference was initially believed to be an unconscious phenomenon providing an impediment to progress in the analytic encounter. Analysts sent their candidates for more analysis to overcome the perceived block in the analytic work. Cautious to not sway too far adrift, the early writers viewed countertransference as negative and something to avoid. The bold writings of early theorists such as Ferenczi, Balint, and Sullivan―then later, Winnicott, Heimann, Racker, and Little―helped open the doors for further exploration of countertransference, its origins, and its uses. Prior to World War II, discussion of counter-transference in the literature and consulting room was limited. Freud’s influence had an impact on other’s opinions of counter-transference at the time. Although he acknowledged the subject, he did not develop the idea and essentially “dropped the subject,” choosing to focus on other aspects of his developing theory of the mind. Several factors changed this picture. Experience in the Second World War put analysts in touch with a wide variety of mental conditions, particularly trauma and its effects on the personality. This led to a greater interest in working with patients outside the realm of the strictly neurotic. And as analysts expanded their practices to include more of the ‘widening scope’ type of patients, they often found themselves experiencing powerful and troubling emotions evoked by the blatant sexuality, the raw aggression, and other primitive effects directed at them by these patients. It soon became evident that countertransference was a major consideration in working with the borderline and
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psychotic patients that analysts were now attempting to treat. (Jacobs 1999, p.580) American analysts continued to adhere to traditional views of countertransference almost 30 years beyond their counterparts in other parts of the world, such as England, South America, and Europe. Fearing the diluting of Freud’s original ideas, they adhered to a traditional view of analysis and countertransference in particular. Not much was written in the American journals, with a few exceptions (Jacobs 1999, p. 582). Otto Isakower attempted to influence the discussion of countertransference in American psychoanalytic circles as did Fromm-Reichmann, Tower, Benedek, and Gitelson. Although their writings were valuable, they failed in winning over the American analytic community on the subject of countertransference and its usefulness in the analytic encounter. It was still believed that “countertransference was a problem to be dealt with personally—and privately—by each analyst; a view that held sway in the US for more than two decades” (Jacobs 1999, p. 583). In other parts of the world, countertransference was openly discussed and studied as a legitimate analytic tool. The late 1970s in America saw more openness to the analyst’s countertransference. As the influence of the older European analysts diminished with the passage of time, analysts in America became increasingly exposed to ideas outside the Freudian canon. The work of Racker, the English object-relations school, and the Kleinians became more familiar and stimulated interest in the analyst’s subjectivity and the way in which it reflected aspects of the patient’s inner world. There was greater contact, too, with colleagues in America who were trained in the interpersonal and cultural schools and whose exposure to Sullivan (1953), Thompson (1964), Fromm-Reichmann (1950) and
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Horney (1939) gave them an understanding of the interactional and intersubjective aspects of analysis that were little emphasized in classical training. (Jacobs 1999, p. 585586) Countertransference and its usefulness in clinical social work were confirmed in the writings of Kohut. His notion that the subjectivity of the analyst, including countertransference, is essential helped broaden the discourse on the topic. Where once the analyst might avoid sharing countertransference reactions with supervisors, the contemporary approach of embracing and working with countertransference spurred a flood of writings on the subject (Jacobs 1999, p. 585). This new openness gave a way for authors to write about “countertransference, enactments, intersubjectivity and self-analysis.� Some of the influential authors include Gill, Poland, Schwaber, McLaughlin, Gardner, Boesky, Chused, Ogden, Renik, and Stolorow (Jacobs 1999, p. 585).
Contemporary Theory Stephen Mitchell’s Relational Theory provides the theoretical lens for this study of therapists working with parents who have lost or are threatened with loss of custody of their children. Whereas the early theorists surmised that countertransference impeded the analytic process, contemporary writers embraced the concept and its uses in the clinical encounter. For instance, before Mitchell, Stolorow celebrated a new way of viewing countertransference. Stolorow was one of the individuals influential in developing current thinking on the topic of countertransference and the subjectivity of the analyst and analysand. As an
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intersubjectivist scholar, Stolrow and his colleagues developed a theory of the mind, described as follows: Intersubjectivity theory is a field theory or systems theory in that it seeks to comprehend psychological phenomena not as products of isolated intrapsychic mechanisms, but as forming at the interface of reciprocally interacting subjectivities. Psychological phenomena we have repeatedly emphasized, “cannot be understood apart from the intersubjective contexts in which they take form” (Atwood & Stolorow, 1984, p. 64). It is not the isolated individual mind, we have argued, but the larger system created by the mutual interplay between the subjective worlds of patient and analyst, or of child and caregiver, that constitutes the proper domain of psychoanalytic inquiry. (Stolorow & Atwood, 1992, p. 1) Relational Theory places clinical importance on the intersubjectivity of the therapist as well as the client. For that reason, it was a good lens through which to analyze the data collected for this study. Countertransference and enactments are inevitable, and will be dealt with as such by therapists operating from a Relational perspective. Countertransference for the Relational therapist is an essential part of treatment. It is mostly viewed as useful and something to aid the therapist in gaining access to the client’s inner world. The analyst is constantly in the midst of the transference-countertransference integrations, shaped by the analysand’s relational configurations and struggling to understand and thereby reshape them from within. The aim is to broaden the analytic relationship, and by extension the analysand’s other relationships as well, into richer, more dialectical exchanges. (Mitchell, 1988, p. 300)
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Many contemporary writers believe that countertransference has value. Thomas H. Ogden writes: ‌ an essential element of analytic technique involves the analyst making use of his experience in the countertransference to address specific expressive and defensive roles of the sense of aliveness and deadness of the analysis as well as the particular function of these qualities of experience in the landscape of the patient’s internal object world and object relationships. (1995, p. 695) Along with the importance of countertransference, these contemporary writers explore how the transference-countertransference experience can produce enactments that prove to be valuable. Theodore Jacobs was one of the first Relational writers to introduce the concept of enactments (Aron & Harris, 2005, p. 175). Many would follow to describe their experiences with enactments and to further the concept and its uses in the clinical encounter. Therapists may find themselves responding to patients in an uncharacteristic manner. Upon closer examination, the dyad may be able to identify painful aspects of the patient’s history being reenacted in the present. These experiences in the clinical setting can prove to be powerful for moving the treatment in the direction of growth and change. Historically, countertransference was considered something to avoid. The analyst was to be a non-entity in the clinical encounter. Volumes were written to the contrary, and debate ensued. As a result, the psychoanalytic concept of countertransference has been thoroughly examined and many agree that, if handled properly, it is useful for furthering the therapy of clients.
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Theoretical and Conceptual Framework of This Study Relational Theory has provided the theoretical and conceptual lens for the study of therapists working with court-mandated parents. This contemporary psychodynamic tradition is a two-person psychology, distinct from Freud’s one-person biologically based theory. Relational Theory allows us to look at the mutual interaction of therapist and client and consider the social milieu in which they exist. Relational Theory’s use of enactments as tools for discovery in treatment, its emphasis on relationships in the transference and countertransference matrix, its attention to projective identification, and the inevitable participation of the therapist (Hoffman, 1983) in relationship with the patient make it a fitting lens for use in this study. Psychoanalytic theory can be divided into the following pair of broad categories, as described by Borden: “Freud’s classical instinct theory, and the relational paradigm, which takes relations with others, rather than biological drives, as the core constituents of human experience” (Borden, 2000, p. 354). For adherents to the Relational paradigm, relations with others are an essential element in the building of personality, health and wellbeing, and dysfunction (Borden, 2000, p. 354). Relational Theory offers a perspective on what is experienced and enacted by the therapist and client through transference, countertransference, and projective identification. This contemporary psychodynamic paradigm also gives voice to the impact of societal forces such as culture, race, and class, as well as the power structures involved with the involuntary separation of children and parents. These elements of Relational Theory allow for an in-depth examination of therapists working with this population of clients.
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Freud’s theory of mind laid the foundation for psychodynamic theorists to research and study human development and psychopathology. For Freud, relationships with others were sought for the purpose of regulating “instinctual tension” and to “satisfy biological needs” (Borden, 2000, p. 355). According to Freud’s “drive theory,” relations with others serve a distinct purpose. If these needs could be met by an alternative method, relationships with others would be unnecessary. Freud and his adherents considered the person to be “a self-contained system of instinctual energy” (Borden, 2000, p. 356). The idea of the human mind developing in isolation has become a thing of the past for those adhering to ideas developed by Relational writers. Even though a shift away from classical theory has taken place, Freud’s ideas continue to provide rich material for the intellectual mind. Two early writers in Relational Theory, Jay R. Greenberg and Stephen A. Mitchell, wrote about the themes they identified in their study of psychodynamic theory. They believed many different theorists had ideas that ran along a parallel track, giving credence to the importance of relationship in development and psychopathology. Even some theorists studying with Freud challenged the tenants of drive theory and started to expand their study into the importance of relationships. Among these early insurgents were Alfred Adler, C. G. Jung, Otto Rank, and Sandor Ferenczi (Borden, 2000, p. 356). In the 1920s, Ian Suttie outright rejected Freud’s drive theory and suggested the importance of social interaction as paramount in human development and mental life (Borden, 2000, p. 357). Although many still claim allegiance to Freud’s drive theory, on closer examination it becomes evident that some manner of relationships with others contributes to human development and mental life. In 1988, Stephen A. Mitchell referred to a “post Freudian”
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era (Mitchell, 1988 p. 2). Mitchell’s research discovered that many theorists had altered Freud’s original definitions, in order to maintain their claim that their new hypotheses aligned with Freud’s drive theory. Psychoanalytic theorizing developed into what Mitchell calls “the relational model.” He said, “The most creative and influential contributions derive from what Greenberg and I (1983) have termed the relational model, an alternative perspective which considers relations with others, not drives, as the basic stuff of mental life” (Mitchell, 1988, p. 2). Three schools of Relational thought have gained prominence: “object relations psychology, interpersonal psychoanalysis, and self psychology” (Borden, 2000, p. 359). Jay Greenberg and Stephen Mitchell recognized the importance of the three schools and through their study “identified shared assumptions, concepts, and themes that served as the basis for their formulation of the relational paradigm” (Borden, 2000 p. 363). When the term “relational” was first used by Greenberg and Mitchell, Relational Theory was distinguished by a rejection of drive theory as conceptualized by Freud, along with an emphasis on relationships. In Greenberg and Mitchell’s historical look at the emergence of this new idea, they found that several theorists had explored this notion in their writings (Mitchell & Aron, 1999, p. xvii). Harry Stack Sullivan, W.R.D. Fairbairn, Erich Fromm, Karen Horney, Clara Thompson, and Frieda Fromm-Reichmann were some of the original theorists to gain attention for these new ideas. Along with an emphasis on relationships, what has been termed “interpersonal psychoanalysis” would address a broader social and cultural context and the wide range of vulnerable populations that may present in the clinical setting (Greenberg & Mitchell, 1983, p. 79).
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This broader view is another reason Relational Theory was an excellent lens to use for this study. In the 1930s, Melanie Klein provided a “crucial bridge to the object relations tradition” (Borden, 2000, p. 357). Her new ideas regarding personality development and pathology did not fully depart from classical drive theory but had a powerful influence on the development of subsequent theories and expansion into the next generation of psychodynamic thinking. John Bowlby believed Freud had defined human development too narrowly with his emphasis on biological needs or “drives” (Mitchell, 1988, p. 21). Bowlby argued that the need for mother trumped all others. Just as the infant requires food for survival, Bowlby argued that it is hardwired in us all to seek proximity to our caregivers for survival (Mitchell, 1988, p. 22). For Fairbairn, the struggle to adhere to the theory of mind proposed by Freud became impossible when Fairbain observed the child’s strong tie to an abusive parent. If libido is pleasure-seeking, he wondered how such a strong bond could be maintained with a person causing pain. Similar to Bowlby’s attachment theory and the notion of proximityseeking, Fairbairn maintained that object-seeking is innate (Mitchell, 1988 p. 28). Winnicott posits that the development of the self takes place in the mother / baby dyad with the mother providing a “good enough” environment to support the development of the self. Kohut furthered these ideas, saying the self develops out of the experience of key relationships―or using his term, “self-objects” (Mitchell, 1988 pp. 32-33). At the core of these ideas is the reliance on relationship with others, as opposed to a solitary
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internal process. These and other early psychodynamic thinkers would lay the foundation for Relational thinking as it has evolved today. A key figure in the American interpersonal perspective is Harry Stack Sullivan. Sullivan and colleagues Karen Horney and Erich Fromm “rejected classical Freudian thought and introduced social models of personality development, psychopathology, and therapeutic intervention” (Borden, 2000, p. 358). Political, economic, and social factors became key concepts in Sullivan’s study of human development and therapeutic action, and have influenced continuous advances in Relational theorizing. As parents struggle to maintain or regain custody of their children, the impact of caseworker and judicial decisions become an ever-present theme in the clinical encounter. Relational Theory’s recognition of societal factors makes it an excellent lens for the study of parents involved in the child-welfare system. For Stephen Mitchell (1988), the Relational matrix provides a broad arena for psychoanalytic enquiry. Warning against the mixing of paradigms, Mitchell makes a bold argument for the Relational milieu and the re-formulating of Freud’s conflict theory. The belief held by Relational theorists is that disturbances in early caregiver relationships will disrupt subsequent relationships and factor into psychopathology. Given the impact of early caregiving on the psychological life of an individual and their ability to relate, Relational Theory provides a framework for understanding the intersubjectivity of both client and therapist. In classical psychoanalytic theory, the person of the therapist was largely left out of the clinical encounter. Transference was considered a “distortion, where the therapist functions as a blank screen on whom the client projects and displaces wishes and
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conflicts” (Ornstein & Ganzer, 2005, p. 565). The Relational model acknowledges the therapist as an active and inevitable participant in the transference. This dyadic style encourages the patient to strengthen relational skills through ongoing interaction in the treatment process. Likewise, in the Relational model, countertransference is conceptualized in a manner that encourages its use for deepening treatment. Therapists adhering to a Relational model will be more transparent regarding their countertransference reactions in the clinical encounter with the patient―an idea viewed as error in classical psychodynamic thinking. Enactments provide the therapist with vital information regarding the client and his or her history. Therapists may find themselves reacting to a client in an uncharacteristic manner. Reflection on these encounters promote therapeutic actions and provide a framework to loosen old relational ties and develop new ways of being. Projective identification in Relational thinking maintains the concept of dyadic relationship. Mutual influence in the clinical setting is a vital concept that informs the Relational therapist. Ringstrom (2010) provides clarity with this brief and simple definition: “projective identification is the process by which I unconsciously recruit you into my “optical delusion” and you recruit me into yours” (Ringstrom, 2010, p. 205). Although debate proliferates among theorists regarding projective identification, the fact remains that it can be a powerful tool for identifying enactments and moving the treatment forward. For this study, an understanding of projective identification helped inform the researcher of the impact of client on therapist, and vice versa.
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Relational Theory provides a rich context to explore enactments between client and therapist in the clinical setting. The theory’s emphasis on enactments, transference, and countertransference make it an excellent lens to look through for the study of therapists’ reactions to their clients. This section considered the mandated-client population and potential issues affecting clinical social work with mandated clients. A brief history of the development of contemporary
Relational Theory, with its emphasis on therapist / client subjectivity,
was reviewed.
Hypothesis tested or questions explored. Mandates for parents to engage in therapy to regain or maintain custody of their children provides a distinctive therapeutic triad including the therapist, parent, and mandating entity. The research question was, “Exploring facets of involuntary separation between parents and children: A clinical social work perspective.” This study examines the therapist’s experience.
Theoretical and operational definitions of major concepts. PARENT: A parent will be defined as a mother or father, by birth or adoption, whose parental rights are in jeopardy or have been terminated, due to the intervention of a childprotection agency and by action of the court. CLINICAL SOCIAL WORKER / THERAPIST: A clinical social worker / therapist will be defined as an individual with a Master’s degree or higher, and professionally trained to provide clinical services for individuals and families.
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CHILD PROTECTION/FOSTER CARE AGENCY: These agencies will be defined as the local governing bodies that take jurisdiction in cases of child abuse and neglect.
Statement of assumptions. 1. It was assumed that the therapist is working voluntarily and under no duress to take a caseload of parents whose children have been removed from their custody involuntarily. 2. It was assumed that the training of the therapists under study, although they may be from different fields, are similar, and that they all share common characteristics. 3. It was assumed that therapists under study will be working with parents who have been threatened with removal of their children, or their children have already been removed from their care, by a child-protection agency of the state in which they reside. 4. It was assumed that therapists under study will be working in a variety of settings, both large and small, such as a non-profit agency, private practice, hospital, forprofit agency, etc. Regardless of setting, it was assumed the therapist is working under the direction of a contract or directive of the mandating agency. 5. It was assumed that the parents working with therapists are stating a desire to regain custody of their children and working on treatment goals to that end. 6. It was assumed that countertransference is occurring, but that its therapeutic utility is woefully lost, as it is not recognized by the majority of clinicians.
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CHAPTER III
Methodology Type of Study and Design This dissertation is a grounded-theory study of therapists working with parents who have lost or are threatened with loss of custody of their children. In keeping with current epistemological developments in the twenty-first century, grounded theory as conceptualized by Kathy Charmaz (2006) has provided the guiding principles for this study. Kathy Charmaz’s “flexible guidelines” are utilized for this study. Her use of traditional grounded-theory guidelines coupled with “twenty-first century methodological assumptions and approaches” (2006, p. 9) have provided a thorough exploration of the experiences of therapists working in a clinic setting with parents who have lost or are threatened with loss of custody of their children. Creativity grounded in rigorous study of the subjects and intellectual pursuit has guided the researcher in the development of theory. Rather than the classic way Glaser and Strauss talk about “discovering” grounded theory, Charmaz says, “We are part of the world we study and the data we collect. We construct our grounded theories through our past and present involvements and interactions with people, perspectives, and research practices” (2006, p. 10). According to
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Schwandt, “Social inquiry is a distinctive praxis, a kind of activity (like teaching) that in the doing transforms the very theory and aims that guide it” (2000, p. 190). Using a social-constructivist epistemological stance has guided the researcher to understand the experience of therapists working with parents who have lost custody of their children. It is assumed that the culture, experiences, and language of both researcher and subject will impact the interpretation of the data. “We do not construct our interpretations in isolation but against a backdrop of shared understanding, practices, language, and so forth” (Schwandt, 2000, p. 197). Using a qualitative inquiry method helped illuminate what takes place in the interactions between parents and therapists in this unique clinical encounter. In keeping with Charmaz’s construction of grounded theory, I have necessarily brought to this study my own “interpretive portrayal” of the experience of therapists working in a clinical setting with parents who have lost or are threatened with loss of custody of their children. According to Schwandt, “… knowledge of what others are doing and saying always depends upon some background or context of other meanings, beliefs, values, practices, and so forth. Hence, for virtually all postempiricist philosophies of the human sciences, understanding is interpretation all the way down” (2000, p. 201). It was anticipated that two interviews would be conducted with 15 to 25 therapistparticipants. Participants were added or subtracted based on the level of saturation achieved during analysis of the data. For this study, the definition of saturation was drawn from the work of Glaser:
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Saturation is not seeing the same pattern over and over again. It is the conceptualization of comparisons of these incidents which yield different properties of the pattern, until no new properties of the pattern emerge. This yields the conceptual density that when integrated into hypotheses make up the body of the generated grounded theory with theoretical completeness. (2001 in Charmaz, 2006, p. 113) Grounded-theory guidelines provided the researcher with tools to grapple with current ideas in the literature and make comparisons to the data collected in the interviews. Remaining open to emergent ideas and the development of new categories gave depth and credibility to the study. Provided that new theoretical categories emerged from the data and conceptual relationships surfaced, data continued to be collected. Once a participant contacted the principal researcher, I read from a script (see Appendix A) during a phone conversation to explain the study, criteria, expectations, and how participant anonymity would be protected. Each participant signed a “consent for participation” form as approved by the Institutional Review Board of the Institute prior to taking part in the interview (see Appendix B). To ensure that each participant fully understood the consent form, I took each participant through it and asked the following questions: •
The study includes therapists that have worked with parents who have lost custody of their children or are under threat of losing custody. You have done this work, correct?
•
Are you clear that the research is part of a dissertation study through the Institute for Clinical Social Work?
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•
Please explain in your own words the purpose of the study so I know you fully understand what we are doing today.
•
Please explain in your own words the procedure used for the study.
•
Please explain in your own words the benefits, costs, and potential risks involved by being a participant in this study.
•
Please explain the privacy and confidentiality guidelines that will be followed by me and my transcription team.
•
Are you clear about who you can contact for questions or concerns should they arise?
•
Thank you for going through the form with me. It is clear you understand what we are doing today. Thank you.
Once the potential participant agreed to proceed, demographic information was obtained using closed-ended questions. The interview continued with the first question from the list of semi-structured interview questions (see Appendix C). Clarifying questions then followed as the researcher endeavored to search out the meaning of a statement or “go beneath the surface of the described experience” (Charmaz, 2006, p. 26). Participants were asked for a second interview if they believed they had more to add to the initial interview or for purposes of clarification. For the second interview, participants had the option of speaking by phone. Participants were free to decline the second interview if they felt they had nothing to add. After the interview stage, member-checking was utilized to ensure accuracy of emerging ideas. The principal researcher offered participants the opportunity to review
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the data. A draft of the results was sent to participants and they were offered the opportunity to comment via email or by phone.
Scope of Study, Setting, Population and Sampling Sources, and Nature of Data I sought out a sample of Master-degreed (or higher) therapists working in an agency, clinic, or private-practice setting, such as Catholic Charities, Lutheran Social Services, and Family Services and Children’s Aid. Participants were identified using a purposefulsampling strategy, or in grounded-theory terminology, “theoretical sampling” (Cresswell, 1998, p. 118). Interviews began with therapists working under two different Midwestern state’s contracts to provide services to parents involved in the child-protection or fostercare departments of their county of residence. Interviews were conducted with individuals to help “contribute to an evolving theory” (Cresswell, 1998, p. 118). According to Charmaz (2006, p. 102), “Theoretical sampling involves starting with data, constructing tentative ideas about the data, and then examining these ideas through further empirical inquiry.” Theoretical sampling is strategic. Initial interviews were conducted with therapists working with parents who have lost or are under threat of losing custody of their children. Through the analysis of the data collected, categories began to emerge and subsequent interviews were sought with individuals to help the researcher evolve the emerging theory.
Data Collection Methods and Instruments As Charmaz stated:
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Methods are merely tools. However, some tools are more useful than others. When combined with insight and industry, grounded theory methods offer sharp tools for generating, mining, and making sense of data. Grounded theory can give you flexible guidelines rather than rigid prescriptions. With flexible guidelines, you direct your study but let your imagination flow. (Charmaz, 2006, pp. 15) Sixteen individuals were recruited as participants to be interviewed until saturation was reached. To find eligible participants, the primary researcher posted flyers in organizations such as the Michigan Department of Health and Human Services, Catholic Charities, Lutheran Social Services, and Family Services and Children’s Aid. Each interview lasted approximately one hour. The interviews took place privately, at a mutually agreed-upon site, such as an office or home. In the event that an interview was requested in a home, one of the research team members received the date, time, and location of the meeting to ensure safety for the principal researcher. The interviews were intensive in nature, allowing for the exploration and reflection on the topic. Questions from the semi-structured interview guide guided the researcher in directing the conversation. Throughout each interview, clarifying questions ensured the accuracy of collected data. The researcher established a comfortable environment to encourage thorough exploration of the subject. It was anticipated that participants may have additional thoughts after the interview, so an optional second interview was offered, to take place over the phone or in person. For the purpose of data clarification, interviews were electronically recorded and then transcribed. Transcription equipment and Microsoft Word on a password-protected
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personal computer were used for this purpose. The transcription was done by the interviewer. Documents and electronic backups were stored in a locked file cabinet.
Procedures for Data Analysis Charmaz (2006) guided researcher efforts for a “grounded theory journey,” in which priority for data collection begins with the gathering of data. Charmaz identified the grounded-theory ethnography as giving “priority to the studied phenomenon or process―rather than to a description of a setting” (Charmaz, 2006, p.22). The flexibility of this method permits the unanticipated to emerge by starting with a broad view and allowing for the examination of the lived experience of the participants. As Charmaz pointed out, “Researchers generate strong grounded theories with rich data” (Charmaz, 2006, p. 14). Using the research practices outlined by Charmaz, interviews for this study produced “rich data” that matched Charmaz’s criteria: “Rich data are detailed, focused, and full. They reveal participants’ views, feelings, intentions, and actions as well as the contexts and structures of their lives” (Charmaz, 2006, p. 14). Grounded-theory coding was done in accordance with the ideas presented in Charmaz’s book. By using grounded-theory coding procedures, categories of information were developed using the constant comparative approach. Codes were created by defining what was seen in the data. The researcher conducted initial coding (including in vivo codes), focused coding, and theoretical coding, as defined by Charmaz. Initial coding is the first step in exploring theoretical possibilities in the data. “Initial codes are provisional, comparative, and grounded in the data” (Charmaz, 2006, p. 48). Initial coding can help identify gaps in data and direct the researcher to fill them. The
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coding is provisional, giving the researcher the opportunity to re-name a code to ensure a better fit with participant descriptions of “meanings and actions” (Charmaz, 2006, p. 48). To stay close to the data during the initial coding, the researcher should keep “codes short, simple, active and analytic” (Charmaz, 2006, p. 50). The researcher remains openminded during initial coding, allowing the analysis of data to generate possible theoretical perspectives. By staying close to the data during this phase of analysis, the participants’ voices remain strong and their ideas are formulated into what will later become the core conceptual categories of the study. This contrasts with preexisting categories being assigned to the data (Charmaz, 2006). In the process of conducting the initial coding, in vivo codes emerged. In vivo codes are classified in three categories: general, participant term, and insider shorthand. General in vivo codes are terms understood by the general population. Participant terms are terms used by the study-participant that capture a particular meaning or experience. Insider shorthand codes are terms that reflect the perspective of a particular group of people. All three categories of in vivo codes contributed to the ongoing coding procedure of the study. They too were subjected to the constant comparative and analytic process of the research as set out by Charmaz (2006). Focused coding is the second step in the coding process. “These codes are more directed, selective, and conceptual than word-by-word, line-by-line, and incident-byincident coding (Glaser, 1978 in Charmaz, 2006 p. 57). The focused coding will “synthesize and explain larger segments of data” (Charmaz, 2006, p. 5). Through the process of coding, a deeper understanding of the data emerged. Focused coding helped the researcher sort through large amounts of data. At the focused-coding stage, I
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scrutinized data to determine the most significant and / or frequently used codes that, from an analytic perspective, warranted retention to help organize data. This stage of coding demanded decision-making that impacted the theoretical categories retained for use all through the study (Charmaz, 2006). As Charmaz stated, “Theoretical coding is a sophisticated level of coding” (2006, p. 63). It follows that codes chosen during focused coding help clarify and sharpen analysis. Theoretical codes are integrative; they lend form to the focused codes you have collected. These codes may help you tell an analytic story that has coherence. Hence, these codes not only conceptualize how your substantive codes are related, but also move your analytic story in a theoretical direction. (Charmaz, 2006 p. 63) Throughout the data-analysis process, memo-writing served as a “pivotal intermediate step between data collection and writing drafts of papers” (Charmaz, 2006, p. 72). Charmaz explains that memo-writing helps the researcher capture thoughts and comparisons, make connections, and crystallize questions and directions to pursue (Charmaz, 2006, p. 72). In this research, memo-writing lead directly to theoretical sampling. Theoretical sampling is the next step in the data analysis. The initial sampling in this grounded-theory study occurred at the start of analysis, whereas the theoretical sampling then helped “direct … (the researcher) where to go” (Charmaz, 2006, p. 100). For this qualitative research, grounded theory fit emerging theories with data. Further “empirical inquiry” (Charmaz, 2006, p. 102) was necessary to move closer to the emerging theory. The theoretical sampling was conducted to build up categories “until no new properties”
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emerged. The categories were saturated with data and then sorting and diagramming helped to integrate the “emerging theory� (Charmaz, 2006, p. 113-115). Coding, memo-writing and theoretical sampling moved the researcher into writing the first draft of the study. By engaging in theoretical sampling, saturation, and sorting, you create robust categories and penetrating analyses. Capturing what you have gained in successively more abstract memos give you the grist for the first draft of your finished piece. Sorting and diagramming give you its initial analytic frame (Charmaz, 2006 p. 121).
Ethical Considerations All interviews were conducted with volunteer participants. There was no risk of physical harm. There was a potential for respondents to experience emotional distress while being interviewed, or afterwards, as they considered their work with parents who have lost or are at risk of losing custody of children. Participants were reminded they could stop the interview at any time, without prejudice. Throughout the interviews, I employed my clinical social work skills of assessing distress, debriefing, and referral making. If a participant appeared overwhelmed, the interview stopped immediately, debriefing was commenced, and a referral made if necessary. The names of three local therapists were written on an index card to be left with any participant experiencing emotional distress. None of the 16 participants displayed emotional distress to the point of stopping the interview.
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Informed consent. The first step in the process of protecting the rights of human subjects for this research project was to submit the research plan to the Institutional Review Board of the Institute for Clinical Social Work. The board reviewed the plan to ensure no human rights would be violated and no breach of ethics would occur. Once the plan passed the Institute for Clinical Social Work’s review board recruitment of participants began. Potential participants received the “Individual Consent for Participation in Research� form, from the Institute for Clinical Social Work, in advance of the initial interview. This gave participants time to review the form and develop questions if needed. The standard form outlines the purpose of the study and various elements including benefits, costs, possible risks, privacy and confidentiality, and subject assurances. Participants were asked to sign the form if they agreed to participate and if they fully understood the consent form. Only non-vulnerable adult therapists were sought as participants in the study. Participants were asked to voluntarily submit to an interview and were given the opportunity to discuss the purpose and scope of the study. Participants were asked to sign a consent form prior to the start of the interview. Participants were advised that the interview might evoke upsetting feelings or memories and could be stopped at any time without prejudice. The study population is not considered vulnerable, although the researcher might encounter a fragile person. In such an event, an immediate debriefing would take place with appropriate referrals made if necessary. The researcher would then request consultation from the dissertation chair at the Institute of Clinical Social Work.
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Use of the data. Care was taken to protect the confidentiality of participants and their responses during interviews. The transcription team signed a confidentiality agreement with the primary researcher to ensure the strictest adherence to privacy. Interviews were conducted in a location of the participants’ choosing to ensure their comfort level. Two recording devices were used during interviews, including personal-computer recording software and an electronic recorder. The computer was password-protected and the electronic recorder was in a locked file cabinet when not in use. Interviews were transcribed by the researcher to Microsoft Word on a password-protected personal computer. Only pin numbers were used to identify subjects. Documents will be stored for five years after the completion of the study and then destroyed. Participants in the study can review a written copy of the results of the research once completed, if requested.
Limitations of the Research Plan Grounded theory is the qualitative research method that was used for this study. Qualitative research has both benefits and limitations. One of the benefits of qualitative research is that its rigorous inquiry provides the researcher with a methodology wellsuited to exploring human problems. Cresswell (1998) defines qualitative research as follows: Qualitative research is an inquiry process of understanding based on distinct methodological traditions of inquiry that explore a social or human problem. The researcher builds a complex, holistic picture, analyzes words, reports detailed views of informants, and conducts the study in a natural setting. (p. 15)
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Qualitative researchers are interested in the “what” (Creswell 1998, p. 17) of the phenomenon to be explored. Qualitative research, if done properly, is rigorous, difficult, and time consuming (Cresswell, 1998, p. 9). It can provide a thorough examination of a human phenomenon through the close examination of data and provide a “complex, holistic picture” (Creswell 1998, p. 15). Although qualitative research can provide an exciting avenue for the discovery of information, it can also have limitations. When conducting grounded-theory research, care must be taken not to impose inflexible ideas into the data. The researcher must stay open to discovery. Charmaz (2006) explains that the researcher brings personal bias to the data-collection process, which can provide a good starting point. However, when analyzing the data, there might be temptation to “force preconceived ideas and theories …” (Charmaz 2006, p. 17). Charmaz cautions the researcher to remain open to new data in order to understand the studied phenomenon more thoroughly (2006, p. 17). Member checking was utilized to ensure accuracy of emerging ideas. The principal researcher offered participants the opportunity to review the data. This member checking involved “taking data, analyses, interpretations, and conclusions, back to the participants so that they can judge the accuracy and credibility of the account” (Creswell, 1998, p. 203). The principal researcher sent a draft of the results to participants, who had the opportunity to comment via email or phone. Member checking was done to ensure the validity of results. The data for this project was drawn from a small sample of Midwestern therapists. The population was not representative of a diverse sample of therapists in terms of gender, ethnicity, race, or economic status. Therefore, the conclusions of the study are
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limited. Generalizability is not the goal of grounded theory. Nonetheless, the benefits of qualitative research have provided a viable method for discovering the experience of therapists working with parents who have lost or are threatened with loss of child custody.
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CHAPTER IV
Introduction to Results Sixteen in-person, hour-long interviews were conducted with 16 different therapists over a four-month period during the fall of 2016. The results of those interviews will be described in the following four chapters. The chapters are titled with the themes that emerged from grounded-theory coding of the interviews. All 16 research participants volunteered to be interviewed after seeing the research flyer. Each participant freely signed the consent form and accepted the 10-dollar gift card on offer. All research participants were generous with their time, enthusiastic in sharing their experiences, and open to the researcher’s questions. One participant described the opportunity to share her experiences this way: I knew I wanted to do it but even without the 10-dollar reimbursement, I really like being able to feel heard, or have a view… somebody to hear what it’s like to go through it, because it can feel isolated. Me and other clinicians talk all the time about what we are going through and how can we make it better, or how can we make it more streamlined so we don’t feel so overwhelmed or sad or bogged down. All 16 participants were offered the opportunity for a second interview via phone or in person. All felt they shared their experiences adequately and declined a second interview.
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The interviews lasted between 50 and 85 minutes, with most being approximately 60 minutes. The interviews were audio-recorded and transcribed for later coding. Participants were given options of where to meet. Interviews were conducted mostly in private offices. One took place in the participant’s home, and three in a hotel room.
Member Checking Member checking was conducted in accordance with the research plan outlined and submitted to the Institutional Review Board (IRB) of the Institute for Clinical Social Work. All 16 participants were told at the beginning of their interview that the principal researcher would contact them after gathering results of the study into a rough draft. I explained that I would request voluntary feedback once participants had the opportunity to read the document via email. All 16 participants received an email that included the “Results� documents. I asked participants to review the results and provide any desired feedback. Of the 16 research participants, seven replied to the email saying they read the results and had no further comments. Some expressed appreciation for the opportunity. Overall, the responses were positive, indicating that the work clearly depicted their views of working with this client population, and that they enjoyed reading about others. No additional interviews were requested or conducted.
The Participants All participants worked clinically with parents referred for services by a child-welfare organization due to accusations of child abuse and / or neglect. The participants were
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from two different Midwestern states. All still worked as therapists. Twelve continue to see the clients discussed, and four currently do not. The 16 interviews were conducted with therapists credentialed at the Master’s degree level. One held a doctorate and one was a doctoral candidate. Four of the 16 participants worked in multiple settings. Fourteen worked for private agencies that were paid through a state contract with a child welfare organization such as Department of Health and Human Services. Five worked through a private practice under a private contract with their state child-welfare organization. One worked at a hospital. The number of years in the field ranged from two to more than 40. The number of years working with parents seeking to retain or regain child custody ranged from two to 30. Five participants worked 1-5 years, eight worked 6-10 years and three worked more than 10 years, with the longest being 30 years. Thirteen of the 16 participants had children and three did not.
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Table 1. Participant Data
Participant Data Parent Experience 11-30 Years Experience 6-10 Years Experience 1-5 Years Hospital Participant Data
Private Practice Non-Profit Agency Multiple Work Settings Master's Degree ABD Ph.D. 0
2
4
6
8
10
12
14
16
18
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The Four Major Themes Four major themes emerged during the coding process of this grounded-theory study: 1. The Fabric of American Life That Nobody Talks About 2. The Work Is Hard and Evokes a Variety of Feelings 3. Interference in the Clinical Encounter 4. The Personal Toll of the Work and How to Manage It The following four chapters outline the experiences of this group of therapists. Chapter Five is titled, “The Fabric of American Life That Nobody Talks About.” This theme emerged throughout the interviews, but the title was drawn from one participant who eloquently described her experience as a new social worker and the discovery of the level of child abuse in her community. The interviews brought to light the difficulty of the therapists’ work, in large part due to the level of abuse that occurs every day in America. This abuse is so horrible that most people do not want to hear about it. Participants described their own journeys of discovery, how they learned to accept the harsh reality of child abuse and neglect, how they manage hearing about trauma every day, and how they work with perpetrators. Chapter Six, titled “The Work Is Hard and Evokes a Variety of Feelings,” describes the various feelings evoked by the work. Participants frequently used words such as “hard,” “difficult,” “heavy,” and other negative terms. They explained the many reasons for their feelings, and how they relied on supervisors and colleagues to process the tumultuous feelings that were a part of their everyday work life. Although the work was described as difficult and challenging, it could also be rewarding at times. Participants were asked what the work elicited, and they described feeling hopeful, anxious, sad,
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traumatized, conflicted, angry, inadequate, powerless, disappointed, worried, frustrated, heartbroken, heavy, guilty, stressful, hard, and disheartened. This chapter outlines those responses. Chapter Seven is titled “Interference in the Clinical Encounter.” Once the recording equipment started, I explained to all participants my interest in their experiences working with parents entangled in the child-welfare system. I encouraged them to talk about both rewarding and challenging encounters. Many described feeling an alliance with the abused and neglected children, making it difficult for the therapists to stay focused on the perpetrating parent. The “voices” of the children were loud in the clinical room. In addition, the referring child-welfare agency was always “hovering,” metaphorically speaking, and interfering with the therapist’s ability to empathize with, and have compassion for, the parent. Transference and countertransference reactions were described, although usually not in those terms. This along with the variety of triggered emotions created an environment ripe with interference, which needed to be managed. This chapter reviews that interference in the clinical encounter. Chapter Eight is titled, “The Personal Toll of the Work and How to Manage It.” Participants shared many similarities in their descriptions of the personal and professional toll of their work. Being a new clinician, being a parent, feeling responsible for custody decisions, dealing with life-and-death situations, and working closely in empathic engagement with these parents were all factors that emerged during the interviews. Participants discussed how they learned to identify those factors and guard against the development of negative consequences such as secondary traumatic stress, vicarious trauma, and burnout. These positive resources included the support of supervisors and
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peers, a passion for helping others, having a personality / attitude conducive to this type of clinical work, and a rigorous self-care plan. Participants agreed that working with parents seeking to retain or regain custody of their children is hard. The work evokes many emotions. It can be isolating to talk about a part of American life that many don’t know about and would rather not consider. Therapists found support in trusted colleagues and supervisors. Clearing the interference from the clinical encounter can be challenging at times, especially when working with other professionals who do not share the same values or approach to working with people with problems. Although the work can take a toll on a new clinician, skills like self-care and the ability to seek good supervision and support gradually develop. These skills help the therapist minimize the negative effects of this type of clinical work.
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CHAPTER V
The Fabric of American Life No One Wants To Talk About The participants in this study described a phenomenon common to therapists working with traumatized people. I have often said to students in my classes that I can clear a room of non-therapist / trauma workers in a matter of minutes. The only thing I need to do is start talking about my work. Most people don’t know the degree to which trauma and abuse occur and don’t want to learn. It is too emotionally toxic for the average person to digest. Participants in this study hear about the horror every day and must find a place to manage that information. The difficulty of finding people who understand or want to talk about it can feel isolating. Many people don’t even believe that such things can happen in America. One participant captured the essence of these ideas, as follows: I think just when you are in school for this, or if you are just in the general population, maybe you see commercials about domestic violence. You know that substance abuse exists, and child abuse, sexual abuse, but you think it’s really rare and it doesn’t happen very often. Then after a while working in this field, you realize that, “Wow, this is really common,” and it is pretty disturbing how common it is. People don’t really talk about it, and families don’t report it. This is really pervasive, and it is just this hidden thing in the American fabric that nobody talks about. I thought about my community, “This is a nice place. There cannot be
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that many cases. Maybe there’s a handful of really extreme cases where people have done something really bad and lost custody of their kids.” I just thought there couldn’t be that many cases. When I’m going to the grocery store and I’m walking around town, everyone seems nice and the community is one of the most educated cities in the U.S., according to these polls. It was pretty alarming once I discovered that there are a lot of people that get ordered to supervised parenting and they are from all different backgrounds and socioeconomic statuses. Sometimes the people with the best jobs that make the most money have the most serious substance-abuse issue and they just hide it really well. If I didn’t work here, had not read the court paperwork, I would have never guessed that. For this participant and others in the study, their initial forays into clinical work included these kinds of difficult realizations. Some described their first job in the field as a “trial by fire” or “baptism by fire.” For most, the work was challenging, but with good supervision and support they persevered for several years. Some no longer do the work, but others have seen these types of cases for more than 30 years. The clients themselves create challenges. Working with traumatized individuals and hearing the stories of abuse and neglect can take a toll on a therapist. Plenty of literature addresses vicarious trauma, and the need for trauma workers to develop rigorous self-care routines to ward off negative effects. This group of therapists was aware of the hazards and each participant described the personal safeguards they have in place to maintain a healthy psyche, so they can be more available to their clients, families, and friends.
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Support of Others: Creating the Capacity to Maintain Empathic Engagement Providing the emotional space for clients to grow and heal requires the therapist to be available in a personal and professional way. Study participants talked about the importance of maintaining good boundaries while at the same time connecting with their clients in an intimate manner that allowed for a safe space, in which the client could explore and have the potential to change, possibly becoming a better parent. These therapists always feel the presence of the children involved, so they work doubly hard to maintain a good balance of support and accountability when working with the parents. Sometimes tragedy strikes and therapists must wrestle with their own feelings while at the same time caring for the needs of others. One participant described the death of a client: She overdosed and passed away. I got the text on my phone at home, that there had been a death, and that everybody would need to be prompt in order to get here and be present and let all the clients know. And then you have to be a therapist for them, and provide that space for them and put your feelings aside. Not being able to tell my significant other that, “Listen one of my clients just overdosed.� Maybe we can say that, but then I don’t get to process it, and I have to feed my kids dinner and try to read bedtime stories and do whatever else we have going on.... Colleagues and supervisors understand these situations. They often deal with the same trauma, and can therefore provide a space for colleagues to process experiences, even if only with a quick call on the phone.
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I did have a lot of support from my team when I was working on that case with my immediate supervisor and my closest colleague. I would just pick up the phone and call them when I left the house, because of how crappy I felt. Another participant put it this way: “I would just pick up the phone and call them and I would cry and just say, ‘This is terrible.’ Without disclosing case details or violating Health Insurance Portability and Accountability Act regulations, some therapists would use family members as sounding boards. This helped them let go of the intensity of the work. I would do that with my difficult cases. There would be times that I would kind of come home and vent: “This is what I did today”―you know, with my spouse. You know, just kind of vent, then I’m done. Another participant described a similar method: I generally had an hour commute throughout the day, driving between families. Much of that time I spent on the phone. You know, whatever allows you to decompress. I don’t know; I always had that. If I hadn’t, I’m not sure I would’ve made it through those years. As a contrast to these examples, all participants described having people in their personal lives who don’t understand their work and don’t want to hear about it. Hearing stories of traumatized children and families can take its toll on therapists. Going to court and testifying on behalf of a child and telling the story of abuse and being believed can have a positive impact on the therapist, but at the same time the experience can be traumatizing.
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He was so traumatized and didn’t want to go back (home). I felt so strongly about helping this little boy, so he wouldn’t be forced to go back into this unsafe environment. I agreed to go and testify as to what I saw and what happened when he was beaten. They ended up awarding the grandma full custody. So, I felt good that that happened, but then at the same time it was sort of like re-traumatizing me. Participants were keenly aware that people outside their field of work did not understand the intricacies of the job. As one participant plainly put it, “I don’t think people really understand.” Those steeped in this kind of work have a perspective on American life that often goes unseen by the general population. I realize that my perspective is kind of skewed. Sometimes when I’m talking to somebody, their eyes get glazed, and bigger and bigger and bigger. It’s like, “OK, let’s talk about something else.”
Self-Care Because the work can create vicarious trauma, field professionals generally understand that they must guard themselves from stress during off-work hours. Participants in this study all described some level of self-care that helped them manage the negative effects of hearing about trauma every day. Some talked about how they avoid certain things after work to clear their minds and not be reminded of the seamier side of American life. A popular movie that “everyone” is talking about might be avoided because it has the potential for reminding a therapist of work stress. As one participant stated, “They will
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say, ‘Have you seen this (movie)’ and I’ll say, ‘No we live it every day. Why would I go see it at the movies?’” Being privy to a side of American life that few know about, or care to know about, can contribute to a feeling of isolation. Trying to avoid things that are reminders of the work can sometimes be difficult. I try to protect my weekends as much as possible, but there are those cases that kind of sneak through. You’ll be watching something on TV and it flashes. You think of something, and it kind of drags you back into that thought cycle. Although most jobs have their associated worries, participants generally agreed that their clinical work carries unique hazards. As one respondent said, “We all have times when we worry about things, but with this job it’s really easy to start seeing the negatives and forget that there are positives.” Because these therapists understood potential work hazards, they all described a commitment to self-care, which helped manage feelings. This in turn allowed them to be their best when interacting with clients. Participants knew the risk of developing vicarious trauma from repeated exposure to stories of abuse and neglect. They also recognized that not everyone wants to hear about this horrific side of American life. Participants were all dedicated to the work of helping families heal. They have committed their lives to that cause, and are passionate about their work. However, they did not shy away from talking about the intense feelings sometimes evoked when dealing with difficult parents. Many participants described the paramount importance of facing their feelings head-on and learning how to manage them. This led to the formation of healthy boundaries and the ability to arrive fresh to each client interaction, free of unresolved issues from previous interactions. One participant vividly expressed the
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intensity of feelings related to abusive and neglectful families, saying, “Sometimes I just have to set it aside and distract myself. I like to watch really violent movies, where people get decapitated and explode. I find it a little bit cathartic sometimes. I will transpose faces.” The work is hard. Knowing that parents are abusing their children and nothing can be done imposes frustrations that create an array of difficult emotions, which the therapist must manage.
Working with the System One of my research questions explored what participants said when asked about their work. All respondents had at least one close relative or friend who understood the depth of trauma that the therapists dealt with every day. The therapists felt safe to talk about their work to these individuals, but always while protecting client confidentiality. Participants valued having someone outside the office who understood and was willing to listen without judgement or advising them to quit “that hard job.” This was especially important to those struggling with the trauma and chaos created by a system that does not always prioritize the best interest of the child. Participants described frustration with the child-welfare system and other professionals, which complicated the difficulty of working with clients trying to heal from their own issues and become better parents. The continuing support of loved ones and colleagues provided these therapists reality checks at times when the professionals in the system did not appear to handle things in a sensible manner. “I will run stuff by him,”
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one respondent said about a loved one, “because he knows. So I say, ‘So I’m not crazy?” and he will go, ‘No, you’re not crazy.’” Many described client work as easy and manageable, while their work within the system was almost impossible. You get some workers that don’t help. They are not supportive and they are even dishonest. They mislead the families. Then you are fighting with caseworkers to do their job, and it is difficult. As your peer, you are fighting with them to help this family and you are shaking your head like, “Is this for real? You are supposed to be helping this family and advocating for them and you are not. Help this family.” It just gets to be this crazy mess. Then you understand how the family feels, because the family is not being helped. So, what they are saying is true. These systems don’t help and the family is left feeling overwhelmed. This just becomes a cycle. Families end up losing kids. Most participants voiced the feeling that the system makes it more difficult for parents to heal and care for their children. Interviews with participants included a variety of stories about illogical decisions that lost track of the child’s best interest. For those outside the field, the idea that this is a common occurrence for people doing clinical work is hard to believe. Nonetheless, a flawed system that abuses children and families remains a reality for study participants. “I get tired of fighting with these systems and these people,” one therapist said, “because it feels crazy some days. Am I crazy, or is this system really this crazy? It is unbelievable.” Another respondent expressed the situation like this:
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I feel overwhelmed. It makes me want to quit my job. I feel like the (client) does, overwhelmed. Where do we go for help? Why is this happening? This shouldn’t be happening. We are supposed to be able to count on the systems for help. Why is it a crooked system? I feel the same way basically that the people are feeling. They have to look for another resource or another person to get their needs met. You just keep going, but it is overwhelming and it is anxiety-producing. It is frustrating. I feel like the people do that I work with. I get them. I want to stop sometimes, I do. It is overwhelming at times. The participants in this study mostly did not believe that there was malicious intent on the part of professionals in the system, but they did vividly describe scenarios that would give anyone pause for concern. These scenarios often involved rules and regulations that appear senseless and illogical. As one therapist described: The policies and procedures, the rules that DHS have to follow, are not necessarily logical or clinically oriented or anything. They are just the rules, and they will prevail. DHS has a huge advantage, in that they know these rules, which may not have any logic, any ethics to them. They are just the rules. As long as they follow the rules, they are in the good. You cannot reason it out. That was for me an incredibly eye-opening thing. Most participants felt that the system most often did not act in the best interest of the child, and that the children needed a voice. My interviews discovered that the removal of children from parents and caregivers can cause more trauma than the situation that originally brought the family under the watchful eye of the child-welfare system. Participants often described collaborating with colleagues who saw the children in
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counseling, so they had a keen awareness of the impact court decisions were having on the children. Once the child was taken away from the mom, the only legal recourse was to try to prove that this was legally wrong, and they could not prove that. Protective services followed their own rules and their own protocols. The judge even said, “My sympathy is with you. I think this is an injustice, but it is a legal injustice.” Protective services, they played this one by the rules. Maybe the rules need to be changed. Many described interactions with caseworkers that were complicated by policy. Part of the clinical work includes helping parents navigate their way through the system. When therapists cannot make sense of decisions within that system, it provides difficulties for everyone. I’m trying to think back on the good side of interactions with workers. If we could get on the same page and connect on what’s best for this kid, and how to support them in this environment, that was helpful. The bad side of it was sometimes feeling like they are very black-and-white in the standards that they have to follow. It was hard to figure out how to really do what was best for the family. For them, seeing their dilemma―“I have this policy I have to follow to the letter”―but understanding that reality isn’t black-and-white, it made it difficult.” Not least of all, these kinds of difficulties affected the clinical work between therapist and client. I don’t know that I believe entirely, but I find it incredibly frustrating to talk to these women and say, “Let’s help you make better choices. Let’s keep you safe,”
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and then the courts won’t support personal protection orders. We had a woman that was dragged behind a car. The guy got out of prison and started showing by her work, and they would not grant the personal protection order. It is just incredibly frustrating to try to tell these women to believe in a system that doesn’t believe in them. This layer of American life, where extreme abuse takes place and children are traumatized, does not sit well with clinicians. The added trauma of knowing the system, which is designed to help, can actually make things worse is incomprehensible. Working with other professionals involved with the parents sometimes challenged the therapists. They described that positive collaborations supported their work, but bad interactions added layers of complications for both parent and therapist. I would listen to the things that CPS workers would say to my clients, who had multiple young children, and think in my head, “I wonder if the standard is actually realistic.” People who don’t have kids, or have one child, talking to people who have multiple little kids, somehow thinking you can have eyes on all four, five, or six of them at any one time, and prevent any catastrophe from ever happening. Multiple interviews included the topic of inexperienced caseworkers and inconsistent policies complicating work with the client population. People inexperienced in these types of circumstances find it hard to comprehend, which makes it difficult to help those outside the office understand the complexities of the work. Social workers in the study described the “strengths perspective” as providing a framework in which to approach their clinical work. However, this perspective differed
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from what they observed while interacting with other professionals. One participant said, “The strength- based piece, you’re supported to see the strengths in people. Policies and systems, CPS, police―they are trained to see the negative.” At its core, the participants’ approach to working with these parents sharply contrasted with how other professionals are trained. This caused problems for therapists working from a strengths perspective. Being able to focus on, “What can these people use,” and, “What do they have that could help them succeed”―that helps a lot. It also creates tension with CPS, police, and policy. Without that strength-based focus, (you have a) very clinical, labeling-type counseling. If you do that kind of counseling, it’s a little easier to accept the labels and create this case label about these people, and put a kid in an environment that seems better. But I don’t think it’s the best way. Experiencing these types of difficulties makes it extremely difficult to explain the work to those outside the system. Sometimes they don’t believe it is possible for these injustices to happen in today’s society, I think that has been my hardest thing with working with this population. Looking at the case file, you think, “Why did these parents lose their kids to begin with?” Helping them process their frustrations and trying to not talk negatively about the DHS workers and the DHS process (is difficult). You don’t want to increase that antagonism that is already there but that social justice warrior part of all of us that led us into this job—that, for me, has been the biggest struggle in working with a lot of these families.
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Some participants struggled toggling between clinical work and thinking about policy. Witnessing injustice propelled them to work hard to help families heal and retain or regain custody of children. Working on behalf of families has its own rewards, but when loved ones don’t understand and sometimes don’t believe that these atrocities happen, it can be isolating for the therapist. When I talk about it with my mom or my nuclear family, they don’t really have any idea what is going on. They are always surprised and, “Oh my gosh, I can’t believe that people do that,” or, “I can’t believe that this happens,” and I will kind of say, “You know, it happens a lot more than you think.” Although friends and family members might not understand the work, a supportive supervisor can make all the difference. As one respondent said, “I think that’s more valuable than anything, supervision―just the ability to express how this affects me.” Being able to talk with a person who understood the work was reported as being very valuable and something that helped with the level of difficulty associated with the work. Most participants could describe times when collaboration was good, when it was bad, and when it was somewhere in between. I’ve had cases where I’ve completely disagreed with the CPS or foster-care worker, and I’ve had cases where I felt like they’ve been an excellent ally. Then I’ve had some kind of in-between, where they don’t necessarily agree with me. We’ve been able to work together, so that is sort of a mixed factor. You don’t ever know. Therapists described working within the protocols of their positions, and within a challenging system. Seeking support from supervisors, colleagues, family, and friends
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could help, particularly when those resources understood the fabric of American life that not everyone knows about.
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CHAPTER VI
The Work is Hard and Evokes a Variety of Feelings Introduction Many factors complicate clinical work with parents who have lost custody or are threatened with lost custody of their children. All research participants agreed that the work is “hard.” This theme reflects the core results of this study. Participants described multiple emotions. One person put it like this: There’s all kinds of emotions to go through. You have the empathy and the anger and the frustration and the joys and the excitement. There isn’t an emotion out there that you don’t feel. Yes, there’s a lot of them. There’s a lot of them. Participants used the following “feeling words” to describe their experiences: hard, hope, anxious, sad, traumatized, conflicted, angry, inadequate, powerless, disappointing, worry, frustrating, heartbreaking, heavy, guilty, stressful, and disheartening. They shared their ideas about why the work is hard, but a few factors were most consistent. Research participants who were not parents when they started clinical work but became parents at some point in their career described parenthood as adding to the difficulty of working with this population. It’s like a physical reaction. It just feels gut-wrenching; I know the power of having your kids and the beauty of that. It’s just a basic inherent need. You have
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children because you want to, so for me it’s really hard, weighing my obligation to what I need to do for the children as well as what I need to do for another mother. It just feels impossible, like I can’t make it. It’s a lot to carry, and I know the burden doesn’t lie with me, but it feels like it does most days. Those things (stay) with me and I take it home. Then sometimes it comes up in my own interactions with my own kids and I feel just sad. Another complicating factor surfaced during interviews, specifically the involvement of other professionals in the lives of the parents. The variety of individuals involved with the parents varied depending on the case, but all respondents agreed that having other professionals involved with their clients made the work “hard.” We try to involve all the key players. We are trying to work with foster parents, bio parents, supervision-monitor, transporter, foster-care worker, a parent aide. I would hope they wouldn’t have all these people. It is so many relationships to try to maintain and balance and everybody has their own perspective on everything, including you. Yet we are really trying to play this middle ground, to help people see the child and decide what is best. It is very hard.
Hope Overwhelmingly, participants described starting a new case with “hope” that the parents they worked with would be successful. As one therapist said, “There has to be hope that things can move forward and do better.” Therapists working with these families all described hoping that their service would help parents learn to protect their children and regain or maintain custody. One participant said, “You never know, but you hope. So
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sometimes it’s the cases where you don’t really think anything happened that maybe a lot of things did happen for them.” Although the work is described as “hard,” therapists persevered and worked diligently to assist parents. The commitment to walk beside struggling parents is part of what brings the therapist back to work every day. In addition: What also brings you back is that she (mom) has a positive attitude about it. I have watched her demonstrate that (attitude) in some very difficult situations. So, if you’re willing to go again, and keep facing this head on―I realize it’s not close, it’s not easy―I will go with you. I will support you in that. Although participants described the work as “heavy,” they created ways to maintain hope and to appreciate the efforts parents make to improve their own lives and those of their children, I think that’s the biggest thing with this job. You have to take the wins, and that can be a small thing. It’s not always like “Freedom Rider” moments. You know that movie, it gives social workers this idea that you’re going to affect huge change, this huge overreaching effectiveness, and it doesn’t work that way. Occasionally you might get the shining light moments, but most the time it’s the small things. It’s learning to identify them and appreciate them.
Anxious Participants described feeling anxious while working with parents caught up in the child welfare system. One therapist said, “I just felt like not enough, like I didn’t have enough experience or I wasn’t a parent.” Many participants were young and described
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this work as being their first job out of graduate school. Because of their age, they were sometimes dismissed by their clients as not having enough life experience. This coupled with being childless could make the new clinician feel anxious about working with parents. This increased their anxiety and frustration, since they felt helpless to change the attitudes of those referred to them. Leaving the anxiety at work and not taking it home proved challenging for most in this study. I’m bringing these anxious feelings home and it’s causing me to be a little distant and kind of pulled back, not as interactive. I’m thinking about how somebody else is responding to something that I’ve said or what’s happening with a particular client right now―Are they relapsing? ―so it carries with me. Some days I’m just better at kicking it away than others. Working with traumatized individuals can take its toll and leave one feeling victimized. This adds to the anxiety and can sometimes be difficult to shake. I have tried to take (email) off my phone at night. Then my anxiety caused me to put it back on, because I want to know if there’s going to be an issue. It is hard to let it go and just kind of throw it away for the evening. It’s just not easy to do. Most participants described feeling anxious about their cases at points during their careers, but learned to develop skills at managing the feelings so they didn’t interfere with daily living.
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Sad All participants experienced sadness while working with this client population. The level of sadness varied from therapist to therapist, for an array of reasons. To some degree, respondents recognize that parents can unintentionally abuse and neglect their children, and then get entangled in the child-welfare system. This recognition results in sadness. Maybe the moms do bad things, but a lot of times it’s because of some other kind of illness. They are not doing it because they hate their kids, not most of the time, at least not what I have experienced. They just really don’t know how to get what they need, and then they end up losing one of the most precious relationships and bonds in their life. It just feels really sad. Special difficulty comes with instances in which therapists feel the parent is making progress and there is hope for returned full custody. When the restored custody does not occur, it feels like a tremendous loss, even like a death. Some in this group of therapists were involved with parents at the time that custody of the children was lost permanently. Those cases were profound. I haven’t been there for a termination hearing, but I have been there where the kids have been removed from mom, and they are moving with intent for termination. It is hard. It has happened a couple of times and I’ve been on both sides, where inside I’m jumping up and down with glee because this is finally happening, and then there’s other times where you just feel helpless. You know there’s nothing you can say that is going to in any way shape or form negate the pain and negative feelings these people are feeling. They know that they are not
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going to be able to see their child again until they are 18. The helplessness is the hardest part because we are a helping profession. We are supposed to, no matter what the situation, come up with some interventions, some tools, some pithy remark that fits that moment. And there is literally nothing in that moment. Or in any of the moments after, they will eventually be able to live with it because they are breathing…you have to. Participants described “just feeling sad” and “wishing things could be different” when working with this parent population. The sadness is particularly acute when children are removed from custody or parental rights are terminated. These instances can leave therapists feeling conflicted. The child might have a better life, but the weight of the parents’ loss is still palpable. Not all participants had been involved at the time a removal took place, but some were present moments afterwards, or attended court when the decisions were made. For these therapists, the sense of sadness was overpowering. Throughout the case they may have felt anger toward their client or been anxious for the children, but in that final moment of loss they connected to the client’s loss and sadness.
Traumatized Therapists in this study described feeling traumatized by their work with parents who lost or were threatened with the loss of child custody. The trauma came in various forms, from hearing the stories of trauma, or from feeling responsible for the outcome of the “case.” For those working with addict parents, the trauma pertained to knowing that court intervention could cause relapse. These therapists had to walk the fine line between doing
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good substance-abuse treatment and being mindful of the impact on child custody. The balancing act could provoke stress to the point of being traumatic. Additionally, hearing the stories of abuse created trauma. “It was almost like a vicarious trauma for me,” one respondent said. “When I heard about (the abuse), it was just really challenging. I felt unhinged a little bit momentarily.” As another participant said, “There is a little feeling of helplessness and trauma that comes along with it, because you’re hearing about things that have happened to children.” The parents often came from abusive and neglectful homes. Part of the work with this client population involves helping parents recover from their own abuse and thereby become better parents. Therapists described hearing repeated stories of trauma from parents. However, helping a parent overcome trauma can create vicarious trauma for the helper. (The mother) struggled with a lot of fears that she would be like her own mom, where there was substance abuse and (physical) abuse. She would talk about her own trauma being in foster care. She had an awareness of her fear of being like her mom, and I think at times she could act like that. But I could see the other side of her, too. At times the work can create situations of direct trauma. For one therapist working in a domestic-violence program, a parent’s violence was directed at her. The experience helped her gain an intimate understanding of what the mother must have been feeling while married to the abusive father of her children. Most unsettling to the therapist was watching the children while she was being yelled at, taking it in stride. It was such a normal part of their daily living that they hardly noticed.
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I have been yelled at, and at times I am like, “This is what it probably feels like. I am sitting here trying to watch the kids and make sure they are okay and you are yelling at me and telling me how I am inadequate in front of the kids and they are just watching.” That was pretty anxiety-provoking. The burden of working with this client population also carries with it a heavy load of responsibility, especially when the parent has a serious substance-abuse problem. Therapists described feeling traumatized by that weight, “because that would just be traumatizing if someone relapsed and died,” as one respondent put it. Therapists also wonder if their work will throw a client into a fragile state of mind, prompting the client to return to addiction for relief. “Is it going to cause that person to relapse?” one therapist asked. “Is that going to cause that person to go back out? Is that going to be the time that they die?” This burden was described as “heavy.” Although all in the study agreed they would ultimately not be responsible for the choices of their clients, they still felt traumatized by the possibility that something they did might contribute to their client making a choice that could result in death. Work with parents dealing with the aftermath of child-related court decisions can have a chilling effect on the therapist. Court rulings can blindside not only parents, but the therapist as well. Some therapists had ongoing communications with caseworkers; in these instances, therapists might be privy to court recommendations, and could thereby prepare themselves and their clients for the outcome. However, recommendations don’t always guarantee a judge’s decision. In instances where children were removed or parental rights were terminated, therapists described sometimes feeling traumatized. When a child is being abused and the courts fail to provide protection, therapists
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experience extreme difficulty. As one therapist said, “That was my struggle, maybe more with policy. We don’t have something to prove (sexual abuse), so (the courts) will just keep allowing this kid to be traumatized. Every participant described frustration with the system and the handling of cases. The judges could be very arbitrary. Some of the judges would just do these bonehead things. Really? You’re going to return these kids after we just said that parents are barely eking by? Sometimes no matter what we said, the courts did their own thing. Overall, feeling traumatized by various aspects of the clinical work with these parents was typical.
Conflicted Therapists described the clinical encounter as having multiple “people” in the room. At the fore are the children and their safety. The therapist may never meet the children but their presence in the clinical encounter caused intense feelings. We are working at both ends, which I think is really hard. We are trying to help support the birthparents, but you’re also working with the foster parents. You see that the kids would have a better life with these foster parents, because they have more than the birth mom. The birth mom is living in a one-bedroom hole and doesn’t really have it together. So, of course you feel really conflicted. Everyone reported that internal conflict complicated their ability to manage emotions while working with the parent population. Although parents are referred for services to improve their parenting skills, the therapist often feels caught in a quagmire of parties vying for attention.
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I have been really on the fence here. I have been reaching out to other clinicians (to describe my experience). This is tough. I see it from a lot of different angles now. I hear the girls in the wording (of a report]). I can hear the girls stating why they might not want to go right back with mom, but then I’m sitting face-to-face with the client …” Therapists described the difficulty of staying focused on clients’ needs when the psychological presence of others entered the clinical encounter. It could be the parent’s children, or the demands of the state child-welfare system. These competing forces often left the therapist feeling conflicted.
Angry Participants described feeling a sense of responsibility for the outcome of parents’ cases. All participants worked with parents with open Child Protective Service or fostercare cases. Parents are often mandated to treatment, and treatment goals generally include the improvement of parenting skills. This made the clinical encounter ripe for multiple feelings on the part of the therapist. There are definitely times that I felt like these kids would not be best in the home. Then I often felt conflicted because on one hand, you could see how it would be bad for the kids, but then you could see how it could be good for the kids. This feeling of responsibility for the outcome made the work difficult for most, with one therapist saying, “It is very difficult work. I have been here almost 10 months and I told my husband I can understand why people come and go like a revolving door.” Without exception, participants described feeling angry with their clients.
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I think this is also where I tend to go―you are just angry at the parent. You feel your own personal anger, if they are not doing what you feel they should do. If they are not protecting their kids, how come they couldn’t? How come this, how come that. When the therapist could not fully engage a client in treatment, a level of frustration and anger took hold. A young therapist said, “Sometimes the frustration would be trying to offer them ideas or solutions, and then they would kind of minimize it because of my age.” At times the anger would escalate to a point that cause some participants to have “unprofessional fantasies,” as they described it. “I have had fantasies,” one therapist said. “That’s part of my coping skills. It is just like thinking of horrible things that could happen to this family, so this child could be free to go live with somebody else.” Intense feelings of anger were described by most participants, and they each had unique ways of managing the feelings.
Inadequate Many participants described feelings of inadequacy, particularly those early in their careers. Many were not parents at the time they started clinical work, which added to their feelings of inadequacy. “I just felt like not enough,” one respondent said, “like I didn’t have enough experience or I wasn’t a parent.” Another participant went into more detail: It is also difficult especially because I am younger. I was even younger at that time, when I would intervene with the parent or try to redirect what was going on.
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They really didn’t want to listen. They would be like, “They are my kids. You don’t know what you are talking about.” Participants who started this work when young consistently reported feelings of inadequacy. They described leaning on older, more seasoned peers. These supportive relationships helped, but often entailed their own difficulties. One participant summed up the overall feelings of inadequacy experienced by the group: Most of us were pretty young when we started out. I didn’t have kids at the time. I was like 22 or 23. You don’t necessarily have the life experience that maybe now I have, being much older, so it was heavy.
Powerless The work left some participants feeling powerless. Most often, these feelings followed interactions with other professionals in the system, in particular when a judge acted contrary to recommendations. As one therapist said, “The arbitrary decision by a judge could change the path of a case, even though we had recommended (something else). So, a lot of times it just felt like … powerless.” Participants described feeling especially powerless when they reported incidents of abuse and neglect and nothing was done. Some told stories of ongoing cases where they strongly believed the child should be removed from the parent’s care, but their recommendations were ignored. This evoked a multitude of emotions, chief among them a feeling of powerlessness.
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A lot of times when you are close with the family, you feel powerless to help with something, like you have reported situations of abuse and neglect and CPS is doing nothing. You’re very concerned. Or the family doesn’t want to engage in services and you know something is wrong, but you don’t have enough (specific information). I think those are the key ways I figured out how to let that kind of stuff go. Respondents agreed that it was important to recognize the source of feelings of powerlessness. Ultimately, each therapist had learned how to manage the feelings and leave them at work.
Disappointing Many of the therapists in this study described feeling disappointed in the outcome of their cases. For some, the disappointment came years later when they learned what happened to a former client or their children. “It was very disappointing years later to find out he was in some group home,” one therapist recalled. Although the therapists worked with parents, they were always mindful of how their work would impact the children. Participants described getting into this field because they wanted to make a difference in the lives of children and families. When they felt they couldn’t, they sometimes became discouraged and disappointed. Clinical work could result in changed attitudes and actions on the part of the parents, or the reverse. Many described situations where they worked hard with parents only to learn that a judge’s illogical decision went contrary to their recommendations and beliefs about what was best for the family. The course of the clinical work could be disappointing at times,
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when, according to authorities, parents did not make sufficient progress to retain custody. On the other hand, situations arose in which the therapist felt the parent was not making enough progress and feared for the safety of the children.
Worry Participants described feeling worried about their clients and case outcomes, but most of all about the safety of children. Therapists hear about the activities of the parents, and they specifically know which parental actions raised the awareness of the child-welfare system. Thus, they are keenly aware of what the children have been exposed to. “I can only imagine with a small child that witnessed his mom [overdose],” said one participant. “Is that going to be burned into him, even though he’s not very big, burned into his memory for his life?” Although the parent is the client, therapists are always mindful of their obligation as mandatory reporters. They worry about the children of their clients, and at times feel compelled to act from a sense of professional ethics. “We have to contact CPS because these children are not safe,” one therapist said. “They are the ones that we have to be concerned about, not the grown individuals.” Another therapist stated, “I wanted to be sure that those children were safe. If they were not safe, I had no problem going to court and asking for parents’ rights to be terminated, and I did. That was hard.” The worry for the children was intense, but worry for the parents also made the work “hard.” One therapist said, “You get a case that has CPS involvement, it is hard to wrap your head around. I think that case will really take a lot of your energy and make you worry about it.”
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Many reported that their clients dealt with addiction. In addition to helping their clients improve parenting skills, therapists were expected to provide outpatient substanceabuse treatment. Participants talked about the demands of treating this type of parent and the ever-present worry that an unfavorable court decision or a mandatory report could throw the parent back into addiction. Addictions mentioned during interviews included alcohol, methamphetamines, and heroin. Worry about a client overdosing became so intense at times that it lingered after work. “We get to wonder all weekend, ‘Did anything happen to them?’” one therapist said. “Sometimes you find yourself checking the newspaper.” Another participant described how worry can give way to resignation: When you see them self-harming, still using, and they sit in front of you and say, “I love my children,” and they share all the things they did wrong, but they still love their children―that’s where addiction comes in. Sometimes I feel like I want it more for them than they (do).
Frustrating The clinical work can be frustrating for various reasons. Frustration can stem from what the client presents, or from interactions with professionals in the child-welfare system assigned to the same case. Each participant described feelings of frustration while working with parents. “For myself,” one therapist said, “there is a lot of frustration and a feeling of being caught. You know what’s right, (but) you don’t have the ability to enforce it. All you can do is try to minimize the damage.” Another participant said, “I don’t have children yet, and they knew that. Sometimes when I would intervene, it would
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be like, ‘You don’t know because you don’t have kids, so you don’t know what it’s like.’” When therapists felt they were doing their part to help but clients resisted their efforts, feelings of frustration escalated. One therapist said, “To me, it was very frustrating because I am doing my piece. I am coming here early. I am coming here on time. I am doing what I said I’m going to do, and I want to help you out.” The competing forces involved with a custody case can frustrate therapists familiar with other kinds of clinical work. “You have so much coming up against you, as opposed to just sitting down with someone voluntarily coming to counseling,” one therapist said. “(Voluntary clients) want help. There is a vast difference between that and all the other stuff that goes along with the requirements.” This frustration escalated when therapists felt powerlessness to make a difference in case outcomes, with many participants mentioning judges’ arbitrary decisions. The biggest frustration would be on cases where you really worked hard. The parents were working really hard. We thought they were going to make it, and then the judge would say, “Rights terminated.” Usually (when) parents were not working, then the judge would return the kids.
Heartbreaking or Disheartening When talking about the children involved with these cases, one participant said, “It breaks my heart.” Other participants frequently used similar wording, especially when discussing outcomes for children. “It would just be disheartening,” one therapist said. “You would see that the mom or parents would get so far, and then they just couldn’t
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sustain it. They just couldn’t keep it going well enough to really have the children.” Recalling a particularly bad outcome for a child, one therapist said, “Honestly, I don’t have the best coping skills with this case. It still has the ability to make my brain and heart hurt.”
Heavy Many participants described more unsuccessful than successful cases. These portions of interviews were marked by a sense of loss, and an accompanying heaviness of spirit. When you experience a loss, you have to grieve it. Eventually you will make sense of it and then you always carry it with you, but it won’t drag you down. That’s sort of how I feel about a lot of the experiences I’ve had with the families I’ve worked with. I will always have them with me and they might sometimes be really heavy, but I have to make sense of them so they don’t drag me down. And I do. And I think that’s a lot of the way I keep doing this. Older participants could reflect on heaviness from their early careers, and how it changed over the years. Many described age and experience helping them handle the weight of the work. Heaviness generally related to the sadness that results from parents who fail to improve, or sometimes even those who do improve. The loss of parental custody was described as “heavy.” Therapists felt this loss on behalf of both parents and children. Some therapists also worked closely with foster parents, so even when biological parents improved and regained custody, the foster parents’ loss weighed on therapists.
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Guilty Participants experienced guilt, which proved difficult to manage. There were various reasons for this guilt, often related to therapists feeling they did not do enough to help a client. She was doing so good just a little bit ago. Now she’s not, so I feel like I failed a little bit. Maybe I didn’t give her enough tools. There is a lot of guilt that comes along with it, but maybe I haven’t lived up to what I should’ve done. Younger participants felt their skill was lacking, which caused feelings of guilt when clients did not make progress.
Stressful Toggling between feeling responsible for custody decisions, and feeling powerless, can create stress. He was engaging with this little girl. Obviously, there was some amount of attachment. Maybe my internal struggle is that question, like, “At what point is the trauma of removing them (from the home) worse than, or any better than, leaving them in this difficult environment, and just supporting the parents?” But I wrestle with not knowing which is best long-term. Most participants reported feeling somewhat responsible for the outcome of a custody case, but also realized that they are only part of a larger system intervening on behalf of abused and neglected children. Client work provided its own stress, and dealing with the many systems in play added pressure. Interactions with other professionals, especially ones therapists might be at odds
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with, also created friction. At different points in their careers, these therapists learned that some things were out of their control, and if they didn’t learn to manage stress, they would not be able to continue. Each participant reported feeling sad while working clinically with these parents. “I did everything in my power,” one participant remembered, “and things didn’t happen for them. It does, it makes me sad.” Feeling powerless to change the outcome of a case also evoked strong feelings. Most days those things carry with me. I take it home, and then sometimes it comes up in my own interactions with my own kids. I feel sad and I just wish things could be different. So, there is a little feeling of helplessness that comes along with it. Feeling powerless was described as evoking stress with these already difficult cases. Learning to manage the stress was important for this group of therapists. In summary, most agreed that working with parents who have lost child custody or are under threat of losing custody can evoke a multitude of feelings. Overall the work is hard; “…the weight of it is very great.” The numerous feelings that get evoked include: 1. Hard 2. Hopeful 3. Anxious 4. Sad 5. Traumatized 6. Conflicted 7. Angry 8. Inadequate 9. Powerless 10. Disappointed 11. Worried 12. Frustrated 13. Heartbreaking 14. Heavy
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15. Guilty 16. Stressful 17. Disheartening
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CHAPTER VII
Interference in the Clinical Encounter Therapists in this study experienced interference in the clinical encounter. The interference takes many forms and adds a layer of difficulty to the work. This chapter will explore the causes of interference as described by this group of therapists.
Four “People” in the Room One overpowering source of interference in the clinical encounter is the presence of “others” in the room. Even though the clinical work is one-to-one, it feels as though there are “others present.” One “other” is the “system” and another is the “children” of the parent in treatment. Each participant talked about “others” in a variety of ways and agreed the extra “noise” in the room complicated their work. Most parents are referred to counseling services by the local state child-welfare system. Parents are expected to resolve the personal issues that cause them to abuse and neglect their children. Since most parents are referred by the mandating agency, it is expected the therapist will report progress, or lack thereof, to the referring agency. Participants agreed it was difficult to avoid the reality that the “system” influenced the clinical encounter, making the idea of “three people in the room” a formidable reality. All participants also talked at length about their allegiance to the wellbeing of the children of
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their clients. The children’s “presence” in the clinical encounter was experienced by all in the study. One participant explained that the interference, including the children, made it “four people in the room.” Research participants talked at length about their commitment to the wellbeing of their clients’ children. These different entities competed during the clinical hour, making it difficult or even impossible to focus on the client. I believe families should just be able to be together, if at all possible. I am thinking of those kids. For me you’re not just asking (the client) a question. You are trying to decipher between the system, the kids, and the parent. It’s like I’m going on a navigation expedition. I am trying to get to the source, which is just the client, but I can’t because all those elements come along with her. It is hard to separate all of them without breaking something in the process. For some, awareness of the children mitigated their ability to be fully present for the parent. “It just really messes with your feelings and your thoughts,” one therapist said. “Not only, “How can the parents be like this?” It’s also, “Why doesn’t someone protect these children?” Another participant said, “I can hear the girls stating why they might not want to go right back with mom, but then I’m sitting face-to-face with the client.” Finally, a therapist summed up the feelings of many of her colleagues, saying, “I have always loved kids and felt kids needed a voice.” The strong voice of the child competes for attention as the therapist works with the parent. The therapist sometimes feels conflicted in loyalty. The parent is the client, but the referral concerns the safety of children. This can result in a clinical encounter with heavy interference.
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Several people in the study came into the field thinking they wanted to work with children. Some quickly learned that by helping parents improve, they in turn help the children. When I went to grad school I was all about, “I want to work with those kids. I want to work with kids who have abuse and neglect issues.” I did work with kids with many different issues for a while. Then I just realized the work is really with the person parenting. Being there for a kid, being consistent and caring and loving and fun is very valuable, but it is more valuable if a parent knows how to do that stuff. By doing good clinical work with parents, some felt the added benefit of knowing they were doing their part to ensure the safety of the children, which quelled the interference. Participants were honest about their loyalty to the children even though the parent was their client. One therapist said, “It was difficult because I sympathize more with the children. Sometimes it’s hard to watch and think, ‘How could you have done this to your kids, or in front of your kids?’” Social workers are trained to advocate for their clients and approach each individual using the “strengths perspective.” At times this approach runs counter to how other professionals have been trained and approach the same cases. In the clinical encounter, interference can come from other voices that insist that children will be at risk if a parent retains or regains custody. One participant described it this way: People in the system will fight back, so you’ve got to continue to validate. Then you wonder and you doubt yourself. “Am I fighting too hard for one client?” We can’t determine what’s going to happen in the future. We just know what we see
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now, but when the CPS worker or the probation officer says, “They’re never going to change,” and you fight so hard for somebody to come back, that carries a weight. What if something else does happen? I just now advocated so hard for this person. What if the bottom does fall out? Some days it really does feel like an overwhelming burden. Some talked about their fantasies of creating a “better way” to intervene in the lives of these families. I just feel like people get into social work for different reasons but mostly because you want to help people. I always loved kids and I always wanted to make a difference. Over time I think I felt disillusioned. The legal system wasn’t always fair, people were fighting, and the kids were caught in the middle, like a bad divorce. I started feeling like, “God this is not working. Maybe we need to think of another way to do this.” At times the work can be discouraging, as reflected in the statement above, and the clinical work can get sidetracked with thoughts of system change. Most participants were parents at some point during their careers. Some felt that having children made the work more important and, at times, more difficult. Those without children cited youthful energy and childlessness as contributing to their past success. As one therapist said, “I don’t think I would have the patience that I had then. I don’t know that I could stay as positive. I am probably much more jaded now. I’ve seen too much, know the realities, you know, what really happens.” For some, parenthood enhanced their ability to understand their clients and gave them more tools beyond their professional training. “I think it’s not that being an infant mental
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health person told me what to do. It told me how to be and that is sort of the gift that you get in relation to your own parenting.” Being a parent while doing this work gave most participants reason to pause and evaluate their clinical work and the experience of parents at the hands of other professionals involved with their cases. I often really wrestled internally with cases. If I really were to step back, I wondered if this could happen to anyone. Why was this person involved in this case with CPS? In my own life and my friends’ lives. Where could that have happened? That internal struggle was there. How much of this is because a parent really doesn’t know, and how much is it a parent made a mistake, just like we all do? Being a parent can enhance the work with clients, but it can also cause interference when the mind wanders during sessions to thoughts of self. Countertransference reactions during sessions can be useful if self-awareness is high. The therapists in this study reported feeling that having children of their own sometimes helped them relate to what their clients were experiencing. They felt it gave them an extra dose of empathy and ability to connect on a deeper level. “Yes,” one participant said, “being a parent helps (me) connect and understand their experience and normalize it.” Sometimes being a parent and living in the same town as your clients can cause an added layer of difficulty. When one of the treatment goals is to “enhance parenting skills,” it can be challenging when your client meets you at the local grocery store at the same time your three-year-old throws a tantrum. Some therapists felt under a spotlight in how they parented their own children. It is both beneficial and challenging to be a parent
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while working with parents monitored by child welfare. Overwhelmingly, the therapists in this study found it to be enhancing, while at the same time it did not minimize challenges. Sometimes when the client’s children are in foster care, conflict arises and the interference intensifies. Staying focused on the clinical issues presented by the parent can get cloudy when even more voices enter the clinical room. One therapist reflected, “Being caught in the middle of that, you are hearing both sides. It’s like being in a bad divorce.” Although this was not true for all participants, some also had contact with foster parents as they worked to help parents regain custody of their children. This dynamic created interference in the clinical encounter. The competing voices in the clinical hour make the work difficult, but not impossible. One participant said, “I think it creates barriers at times during the treatment process.” Each participant described their efforts to “clear the room” so they could focus on the parent. Acknowledging the competition for clinical attention and then working together with their client to focus on treatment goals helped therapists stay fully engaged with their clients. For most participants, interference in the clinical encounter was most profound when the child-welfare system (“the system”) was “present.” Components of “the system” were described as caseworkers (both Child Protective Services and foster care), and the court (police, lawyers, and judges). Most parents receiving counseling services from this group were mandated to treatment by workers in “the system.” Getting clients motivated, and
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keeping that motivation throughout treatment, presented some challenges for participants in the study. It was difficult because they didn’t really understand why they lost their children. They had difficulty taking accountability for it. I think the first piece was helping them take accountability for what happened. If you keep saying it’s not your fault―it’s the state’s fault; I didn’t do it―that is not going to bode well for you. You need to accept what you did and make some changes because the state does not take your kids away for no reason. Another therapist focused on parents’ motivation: You can try to help them find motivation. You’re stuck trying to motivate somebody who feels like they’ve done everything they can. And I feel like I’ve done everything I can. I’ve done all the motivational interviewing and (used) all the tools in my toolbox to try to help them care. Sometimes the parents just lose that caring. One interviewee shared insight on working with stubborn parents: I want the best for everyone. I want to provide them with this information. I came to help them, but there’s a difference between me giving it and you receiving it. When I work with the parent who particularly does not want to receive it, it makes me wonder, “If I don’t do my job, then she is going to go home and this is going to happen.” It’s like I have to try harder, and it is too much pressure. The pressure to have clients succeed and improve their parenting skills is compounded when parents do not take responsibility for their actions early in the process. It can prolong the work, and with state regulations dictating a limited number of months for
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cases to remain open, the therapist can feel overwhelmed. The added pressure of building a therapeutic alliance quickly and getting the work done is a reality for therapists. Commitment to the mandating agency sometimes caused therapists concerns when intervening in the lives of their clients, and when working with those they supervised. If they oppose the mandating agency too strongly, they could potentially jeopardize future referrals. For a few participants, their roles as administrators gave them an additional burden. My staff was concerned about the kids in the family. They were frustrated. We are a contract program, so if our main referral source doesn’t like us, what is that going to do to the jobs and positions? There is concern for the family, future referrals, and those relationships that we built. There’s a lot of different levels to that. Similarly, when an individual in private practice disagrees with the mandating agency, it can mean a loss of income. As one participant said, “That was the first case I had in three years from (the agency), because I spoke against them.” For the participants in this study, ethical work took precedence over referrals. They continued to do what they felt was right for the families they served. It did not diminish the interference that complex layers of concern can create in the clinical room. The court has jurisdiction over open child-welfare cases. The workers are required to give updates until the cases are closed. This involvement was described as ever-present in the clinical encounter. It really just depends on the case. Most of the time, there’s just a vague underlying expectation of frustration when you’re dealing with the court, sort of
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like running a low-grade fever. It’s there, but it’s not really getting in the way of anything, but (it has) occasional spikes. You just kind of get used to functioning at this level. There are the spikes, but most the time you just get used to the vague level of frustration. Occasionally it goes really well and you are surprised. This frustration carries with it a level of disappointment. There is usually this animosity between whatever agency you’re working for that’s responsible, and that parent. I haven’t had very many rewarding experiences where mom got it together and the kids went home and stayed home. I can’t think of any. Yeah, maybe there was one or two but I’m not recalling it. Speaking about the level of frustration, another therapist said, “You either like that, and you can adapt to it, or you get out. You can burn out pretty quick. You have to be able to manage and juggle, be adaptable and flexible.” The therapists in this study were mindful of their level of frustration with the work. A few got out before it was too overwhelming. Those still doing the work have found ways to manage negativity. Participants reported the necessity of communicating to clients that the therapist is not “the system.” The therapist is often confused with “the system” and parents don’t always know the difference. Therefore, therapists must clarify their role in the case work. As one therapist said, “We get associated with the department and CPS and foster care when we are doing these interventions or reunification programs. They think we have the power to remove their kids, or we are the decision-maker, and we are not.” Clarifying the role of the therapist can aid in successful clinical work. There is greater potential for a trusting relationship, which can enhance the clinical encounter. For this group of clinicians there was a keen awareness of “the state” being present in the clinical
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encounter. As one participant said, “I learned quite early to get the state as small in the room as possible. We would, from the get-go, talk about our role, how we weren’t the state, and what our purpose was.” Usually therapists dedicated time to explaining their role to the parents. Participants described being very transparent regarding their obligations to the state. They were clear about their duty to write reports, talk to caseworkers, and testify in court. Some would even read their reports to their clients before they were sent. This was described as a component to building the therapeutic alliance, which decreased the size of “the system” in the clinical work. When we open a case, I will tell the family, “You need to know I am here to help you and this is supposed to be client-driven. We have these things that DHS would like us to work on, but what would you like to work on? How would you like that to be interpreted? We can work with that, but you also need to know we are mandated reporters so if I see anything, or if I feel like your child is at risk, I have to report it, or I can lose my license. That is just the reality. I have to be in contact with your worker every week. It doesn’t mean I have to tell them everything we talk about, but if there’s something concerning, I am going to have to let them know because if something happens, I can be held liable and the child could be put at risk. So, I try to lay all that out. This level of transparency in the clinical work was described as helpful, especially in reducing the interference of “the system” in the clinical encounter. Sometimes the mandates of the system made it difficult to help parents accomplish their goals. Most states have time limits for parents to make positive change and
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demonstrate their abilities to parent effectively. When that time runs out, therapists often feel backed against the wall. We can use this mother for instance. She is sitting there, telling me the stuff. I am sitting there thinking, “I have to write this up in this report. I cannot have six more months to help this mother get it together.” You have this amount of time to get it together and that is that. Her time was up. I am talking the last session. She almost made it. When a case has been open for the allotted amount of time granted by the mandating agency, the therapist must adhere. If a parent starts to open up at the end and disclose reportable offenses, sometimes the therapist has no alternative but to report to the caseworker and close the case. Some participants described advocating for additional services, without success. On that topic, one participant said, “Again, that is some of the frustration.” Parents’ anger at a system they feel is working against them can be a hindrance in the clinical work. Therapists described spending some of their clinical time helping parents overcome their anger at “the system.” One participant said, “Usually in those situations, anger towards the system was a huge part of what kept them from moving forward.” Helping parents manage this anger often consumed a big part of the clinical work. A therapist said, “She had no trust for the system. I am trying to have her work through some specific experiences and emotions. It is difficult because the ghost is behind her, whispering to her, and I can’t get past that.” When the therapist could reduce the “people in the room” to two instead of four, interference in the clinical encounter lessened. The therapist’s ability to connect on a deeper level with their client was realized.
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Transference and Countertransference Most participants voiced an awareness of interference in the clinical encounter that can be caused by transference and countertransference. Only three participants used those specific terms, but others described clinical encounters that meet the definition of each. All participants in the study were mindful of the fact that they bring themselves into each clinical encounter. They were cognizant of the necessity to address any personal issues they regarded as interfering with their clinical work. If it is an issue that keeps coming up, I need to take care of it outside of supervision. Maybe once or twice is not an issue, but if you are having it on a monthly basis or something, and you are making choices based off of emotions, I think supervision can only go so far. Supervisors are not meant to manage emotions. They are meant to help you figure out how to manage your emotions. Spending time in personal reflection and going to therapy was reported as helping with these kinds of emotions. I have spent some time reflecting on why is it so hard for me when he (family member) does things that make me crazy, and why do I give people I work with so much slack when they are kind of engaging in the same thing a lot of times. It is because the people I am working with are working with me. They have some inkling that they would like me to help them with something. Others in the study described similar personal triggers. In certain instances, the therapist’s early life resembled a client’s, and that familiarity could cause interference. For one therapist, entering a home similar to the one she was raised in triggered a reaction. This helped her align with the children in the family. Recognizing the
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“trigger”―not ignoring it―helped move the treatment with the parent to a deeper level. The therapist could then help the parent understand the children’s feelings and perspective. This was one example of participants describing their personal journeys while developing as professionals. There was an overall general acknowledgement of the interference that could be caused from unresolved personal issues. During research interviews, learning not to take client decisions personally provided a topic of discussion. Participants were very forthcoming with their descriptions of their own personal triggers evoked during clinical work. She made the empowered decision to leave him, make a life. We were really supporting her. She got her kids back. They had been in foster care. Then like three months later, she goes back to him. Like, “Really? How could you do this to me?” It felt very personal, even though people have a right. It was just maddening. You want to bang your head against a wall sometimes. You are doing so much work, and then they just like go right back to the situation. Since many started doing this work early in their careers, it was difficult to not take things personally and not have it impact their growing professional identity. As one participant recounted: The parents were so hung up on what had happened that they couldn’t easily move forward. We were struggling to help them. On the one hand, “What am I (the therapist) doing wrong,” and then on the other hand, “Why can’t they get over it?”
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Several participants talked about questioning their professional judgement. Being dismissed because of age did not help build positive relationships for new and eager therapists. Foster parents and the birthparents would be sometimes dismissive of my age. They would say things like, “Just because you go to college doesn’t mean you know how to parent. You don’t have kids.” You don’t necessarily have to have kids to know how to use good parenting skills. Sometimes the frustration would be trying to offer them ideas or solutions, and they would kind of minimize it because of age. Some described being new and lacking in confidence. “I don’t think I felt super accomplished,” one participant remembered, while another recounted post-session blues: “Did I really do anything in that hour and a half that I was there? Did I really do anything? That’s kind of how I felt.” This kind of self-doubt could be debilitating, with one therapist saying, “You stir some self-doubt, and you start wondering, ‘Is this even what I’m supposed to be doing? Am I doing the right thig?’” For the study population, countertransference was an inevitable part of their work with court-mandated parents. The term “countertransference” was not used by most participants. However, they all described ways in which their personal issues interfered with the clinical hour. Many explained how they used countertransference to enhance their work. For others, problematic countertransference motivated them to search for effective management tools. That meant more supervision or time at the gym, while others went back to therapy or began medication.
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Overall, interference in the clinical setting involved at a minimum the “presence” of abused and neglected children, along with the demands of the child-welfare system. This formed what I call “four people in the room.” This interference can hinder the clinician’s ability to focus on the client and case work. The interference intensified when emotions came into the clinical room and transference and countertransference arose. Participants agreed that acknowledging this interference was the first step in overcoming it, to ensure the quality of their clinical work.
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CHAPTER VIII
The Personal Toll of the Work and How to Manage It Occupational Difficulties All participants discussed the difficulty of clinical work with court-mandated parents. They additionally defined which aspects of this work took a personal toll. These factors included being a new therapist, dealing with life and death matters, the feeling of having a personal “mission” or life’s calling, carrying the work home, feeling responsible for custody decisions, and parenting errors that can happen to anyone.
Being a new therapist. Developing a professional identity is an important developmental milestone to accomplish for the new therapist. Working with mandated clients can challenge the most seasoned therapist. Newly out of graduate school, the therapist learns the demanding realities of being a therapist along with managing the emotional minefield of sitting with and hearing the stories of traumatized people. “It takes a toll on you,” one participant said. “You really question who you are, what you have to offer. (You wonder), ‘Am I hurting someone?’ That is the last thing that you want to do. That is not why you got into this.”
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To feel competent and professional, one generally needs some experience. Most therapists in this study did clinical work early in their careers, and only a few did it long term. They described the toll the work took on them early in their careers, how they used their mistakes and their experiences to learn the craft of therapy, and how to manage their feelings. One participant with more than 20 years of experience described how she learned to lessen the personal toll. I do yoga a lot and, so I have learned that I do what I can during the day. I work hard but when I’m done, I’m done for the day. It wasn’t always that way. When I was younger it was hard to let it go, but over the years if you want to keep doing it, you just have to recognize you can only do so much. You do a lot during the day and then you let it go. Knowing how to intervene with clients is another skill developed over time. A new therapist doesn’t always know what is best, so self-doubt can creep in and cause anxiety. Most participants said the emotional toll lessened when they were confident that they had done the best for the client. As one therapist explained, “As long as I can say I did what I could in the situation, I’m OK with it. The only time I really struggle is when I feel like I didn’t pursue options to do the best I could.” When speaking of feeling competent, therapists said they could “let it go” before driving home to their own families, provided they knew they had done the right thing for their clients. But again, for the new therapist, knowing what is best can sometimes be a challenge. Experience gives the therapist a resource to call on in times of difficulty. Getting rid of the self-doubt and really having self-appreciation, because I know that I am doing the best that I could. But when someone questions that, I question myself. I
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need to get to that point where I understand that I am doing everything I can, and I don’t need that extra validation. Most research participants were young when they started working with this population. They found themselves in situations that took an emotional toll on their own well-being. As they reflected on the beginning of their careers, they reported the importance of learning the craft of therapy, but also―and of equal importance―learning how to minimize the personal toll the work can cause. It really is experience, and kind of developing a thicker skin. Working with people in the domestic-violence programs, you can’t just naturally be good at that. You [need] practice of being assertive and hearing all the stories and seeing the patterns. After a while it becomes predictable, so although you are sensitive to it, you don’t get so caught up in it. You begin to understand this dynamic, and it is not so foreign to you. Most therapists make mistakes when they are new to the job. These errors can be catastrophic for families involved in the child-welfare system, and no one knows that better than the therapists themselves. I would have a harder time leaving it if there was a case where I knew I made a big mistake. When I do make mistakes, (I’m able) to recognize it. “How can I work and move forward and fix it,” and, “Where do we go from here?” I have a forward focus. Participants shared the importance of feeling competent. It helped them leave jobrelated feelings at the workplace, reducing the overall emotional toll.
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Dealing with life-and-death situations. Many court-mandated parents deal with addiction or mental illness, which adds extra stress for therapists. Remembering a former client, one participants said, “I still have not heard if it was an intentional overdose. Some of that weight carries with me. Was there more I could or should have done?” In life-and-death situations, questions like these can linger throughout a therapist’s entire career. I did everything I felt like I could do, but there’s still that doubt. You feel like you need to be superhuman. I should’ve been able to do it all. I should’ve been able to predict it and make it different and make it better. Participants shared that learning how to separate the personal from the professional helps minimize the toll of work. You have worked with coping-skills strategies and different things to help this client. You have seen this client working. They have practiced (the strategies). They get it, but they are still feeling suicidal. What am I not doing right? What am I not getting through? What am I not providing what she needs, to help her not want to die? Most agreed that learning to leave work at work is important if the therapist hopes to do the work long-term. Also, understanding how to separate client and therapist responsibilities is part of the learning curve for someone new to the field. However, regarding loss of life, it is difficult to not feel some degree of responsibility.
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The work is personal. The personal nature of the work adds to the hazard of it becoming overwhelming. Each participant described a passion for helping others, and how it drove them to pursue a career in the helping professions. You get up with the belief that you are helping someone. When you see that it is not turning out the way you envisioned, it gets to be discouraging, to the point where you wonder, “Why am I doing this again?” Then you want to switch to (other clients to) see more tangible results. That is when you have to keep in mind, “Am I doing this for me or am I really doing this for them?” Therapists found it important to regard their work as a good fit for their personal strengths. This belief helped reduce the emotional cost. I don’t regret coming to the field. I feel like it’s a good fit for my strengths and my dreams and my passions, all those things. I feel like we make a difference in lives and often I actually feel like we make a difference in lives that we don’t even know, the next generation of the child’s family. However, in moments of self-doubt, the work becomes a heavy burden. It feels like you should be superhuman and you should’ve made it happen. That’s a big thing. For whatever reason, we get into social work. We think we are going to fix people. We are going to make their lives so much better, and then when it doesn’t work―and then when we get blamed―it just validates everything I guess: “I didn’t do everything I should have done,” and it carries the burden. Although the work is difficult, most participants agreed that they would not change their choice to work with this client population. They also would not discourage others
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from joining their ranks. However, they reported a desire to pass on their knowledge so new clinicians can be more realistic. I want people to be aware of how hard it would be when they come into the field. I would not tell them not to do it, if they are passionate for people and helping others and they can stand nasty bugs, stink, sitting with somebody who has a record or is really angry―there might be gunshots outside your door at some point or a drug deal going on around the block―you can make a difference. Facing the truth of what the work entails is part of learning to manage the emotional rollercoaster, a process that gets complicated when therapists place unrealistic expectations on themselves. I am learning I cannot make things happen for my staff. They have to do things on their own, and I cannot make everything happen for the community. I can’t make everything happen for the clients. I just have to be happy with that. That’s just where I keep coming back to, expectation and boundaries, because I’ve been working a lot on that. It is in the doing that skill develops. Each research participant described their struggle to become competent. I believe that every client can teach you something about yourself or about life in general. If I am not being of service to you, I am not helping you to meet the goals that we set forth, then I try to look at it as, “What can I take from this that I can develop as a better therapist?” I am going to get another case like this, so instead of me being the same, how can I be a better me to help the next client (using)
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what I gained and learned from you? Even if I don’t feel like I am winning all the time, if I have that in mind, (I) can begin to make a positive change. The personal nature of the work has positives and negatives. While it motivates therapists to perfect the skills needed to work with mandated populations, it can also take a toll, since the impact of the work can cause lifelong consequences for entire families.
Carrying the work home. With any type of clinical work, therapists must learn how to manage their personal feelings and leave the work at work. However, when working with mandated clients, therapists felt this kind of compartmentalization to be daunting, if not impossible. For some, difficulties arose from specifics pertaining to job responsibilities. Others couldn’t shut off their worry about parents and children. I was on call 24 hours, seven days a week, especially down in (the city) because the (main office) clinicians didn’t want to take any cases. So, I would never forward my phone. My clients would call and if someone else would answer they would say, “Oh, I will just wait.” One therapist pointed out that the ability to separate work from home takes time, saying, “Somewhere between college and two years into my work, I figured out how not to take everything home, how not to obsess over that family, (or) wonder if their kids are safe.” There were a variety of reasons for carrying the work home, but all agreed it was important to learn how to leave work at work.
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Participants talked about the negative impact on their personal relationships when they did not leave their work at work. Some even described the work as contributing to the break-up of their relationships. Juggling commitments to family and a job with high-risk clients proved more difficult for some than others. I took it home, all right. I was doing notes from home. I was completing assessments from home, and it eventually got to the point where my fiancé said, “You need to figure something out. This is not working anymore. You’re saying it’s not me. You are saying it’s not the kids. You are saying it’s not home life. Well, if it is work, then you need to figure that out because it is really affecting your home life.” This level of immersion in the work required therapists to set boundaries. I would be cooking dinner and he would come home from a long day. He would have done absolutely nothing but bring home milk and toilet paper, or maybe flowers, and I’m not wanting to talk to him because I am emotionally drained. It was about this summer that I said, “I have nothing left for my family when I get home. So, where is that boundary?” Boundaries not only helped participants improve their personal lives, but also their effectiveness in the clinical setting. One participant said, “I have to recognize if I don’t have good self-care, I can’t come back to work and do what I need to do.”
Feeling responsible for custody decisions. Most therapists working with court-mandated parents are required to report progress to the court. Participants wrote reports and letters, talked on the phone, and sent emails to
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caseworkers and others, as well as testifying in court. A therapist’s role is generally that of a single member on a larger team, contributing to the success, or failure, of the parent seeking to improve. However, the individual therapist often felt pressure to predict a given parent’s ability to parent effectively. If not managed properly, this added tension could leave participants feeling singlehandedly responsible for custody decisions. [After calling in a CPS report] I sort of felt responsible to help them get (the children) back because I played a role in getting them removed, even though I knew it wasn’t my fault. I mean, the kids didn’t get removed because there were pop-can tabs on the floor. They got removed because there is this long history of a lot of other things happening. My calling [CPS] was like the straw that broke the camel’s back. Court cases often elicit strong emotions, especially when therapists feel that they played a large part in that decision-making. The powerful place you play in those lives, for better or for worse …. What you say in court might matter. All those kinds of things, you see how they get played out. I wasn’t overwhelmed by the work in those early years, like I wanted to quit, but it was pretty challenging. Feeling a deep sense of responsibility for the future of a family could upset the therapists and impact clinical work. You care about the person. [It’s] almost like your friend or your sister kept getting in a bad relationship. Just like with any case, you have to think, “What is my role, and what can I realistically do and help within this case?” Then, “What is beyond my control?”
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Understanding one’s limitations helps reduce the feelings of responsibility for custody decisions. It can also help the therapist refocus on the important clinical work to be done. “[It] ruined that woman’s life,” one therapist said, in reference to a mother losing a son. “But I don’t know, maybe it was a good thing that he got to stay with his dad. I don’t know. I can’t decide that for them.” Another therapist said: It is difficult working with parents who are in the process of working with the foster-care system because you don’t know how it’s going to go. You might not want to give them false hope that, yes, everything is going to work out; don’t worry about it. You have to be realistic. You might get them back and you might not. Knowing that important family decisions are being made and some of that responsibility lies with the therapist is a heavy burden that adds to the emotional toll. Participants in this study agreed that learning to manage those feelings is important for therapists working with this client population.
It could happen to anyone: Parenting. Most participants in this study were parents. They were aware that every day with children presents its own set of challenges. For some, having children gave them a unique perspective regarding how quickly a normal day can turn into disaster, one that could potentially land them under the same circumstances as their clients. They knew that their own parenting was not always perfect; if a child broke an arm, some doctor might feel the need to report “suspected abuse,” with the therapists themselves under the watchful eye of the child-welfare system.
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Describing a specific case, one therapist said, “I wondered if this could happen to anyone. Why was this person involved in this case with CPS, (when) in my own life that could have happened?” Knowing what can generate a referral to Child Protective Services, another therapist said, “It has caused me more anxiety. You can’t leave your kids in the car and walk into the gas station.” Although stressful, understanding the real possibility that this could happen to anyone helped therapists connect with clients. Leaving judgement and labeling at the door was crucial to building a therapeutic alliance. The same can be said of labels given to people, which often fail to fully describe their situations. Some therapists quickly learned to abandon the labeling that occurs within child-welfare system, and focus on getting to know their clients. It is hard not to have preconceived ideas. I never wanted to work with sex offenders. (I always thought) people who do this are absolutely awful, but then you get in there and you meet the people. You start reevaluating what you think about certain labels. You realized some of these labels are not so cut and dried as you thought. A “May-December” romance can turn into something that looks completely different in a court report. Participants said their ability to work across a variety of family circumstances helped parents retain or regain custody. Being open to hearing the full context of a situation proved critical when connecting with clients. Participants also helped people outside of work understand what can result in a referral. This brought a level of realism to the idea that this can happen to anyone.
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I will hear people say things like the labels, like “child abuser.” [I will say,] “You guys don’t understand. I had one case―I think I have used this one because it is such a vague example―someone was changing a baby. It fell off the bed or wherever they were changing and got a broken arm. That was a CPS case. People will look at me like, “That’s a CPS case?” and I’m like, “Yes.” Encounters with parents who have lost custody of their children can provide good reminders to always be fully present with clients without judgement and labeling. She talked about how one night a guy had taken her home. She said he held her for three days and wouldn’t let her leave, so her kids were home alone because the sitter left. They were removed and she lost them. It is hard to know how much of that is truth, but our judgments prevent us from being willing to hear those stories and wonder, “Is this a mom that is doing her best, and then something happens, and she is stuck and she’s traumatized?” While learning to avoid labeling and focus on helping parents is an important part of the work, trying to get those outside the field to understand that it could happen to anyone is particularly thought-provoking. To me that’s part of the work. There is hope, even though maybe you didn’t get it right. I think that’s part of the work that others outside don’t understand. Here is this mom that has messed up her relationships with her kids. Her kids are probably all screwed up because they’re in foster care and blah blah blah. So why should she keep getting chances? Maybe she is going to mess it up and maybe she won’t. Maybe this will be the time. We can’t just assume that people are not qualified to be parents.
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Clients come into the system through a variety of circumstances. This impresses upon therapists how easily anyone could fall into the child-welfare system. Facing that reality and talking about it with supervisors and colleagues can minimize the emotional toll and protect the integrity of the clinical work.
Managing Feelings Required Acknowledging the harsh reality that clinical work has its own set of hazards is the first step in learning how to minimize its negative toll. Participants talked about a variety of ways in which they learned to manage a rollercoaster of feelings. Most came into the field with a personal “passion” or “mission” for helping others. Some described a “personality type” or “attitude” that they believe suited this type of clinical work. Once entrenched in the field, they overwhelmingly credited their supervisors and peer / colleague relationships as necessary supports. Everyone in the study described a self-care plan as necessary for maintaining good mental health and connections with a challenging client population.
God-faith-mission-passion. Participants described their work to create safe havens for children as a passion. “I had a mission,” one therapist said. “I was going to give those children a voice. I was going to help them. I can do that now and that is the best feeling ever.” Another put it this way: I made a promise to the children and myself that I was going to keep going until someday I could find a way to help them have a voice. That is why I am here and went to college for 6 years to get my Master’s degree.
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When the work gets difficult, this original desire to help often sustains therapists. “I am a big believer in God,” one participant said. “He puts people in your life when you need to have them in your life. People come and go. I just want to do the best I can with every one of my clients.” Despite their passion and strong belief that they were on the right path, participants still sometimes felt disillusioned. I got into this thinking, “I’m going to help,” not necessarily a savior complex but, “I’m going to help a lot of people.” Then you get in. You realize the margin that you actually get to help into full sustained remission from substance-abuse disorders, that you actually help get back their children, is a lot smaller than what you would think. I’ve gotten to the point where one victory in a week or two weeks is like, “Yes, we got one,” one person that made the right decision. They didn’t use yesterday but they really wanted to. You really learn to adjust your outcomes and your perspective because it’s not (always) going to be happy.
Attitude. Participants found that a positive attitude contributed to professional success. Number one I think you have to have a positive attitude about people and their ability to change, regardless of their life situation. It doesn’t really matter where we come from; we all put our pants on one leg at a time. I grew up in a quote “better” home, but it doesn’t make me any better than the other person. They just need additional resources and help.” This belief in the capacity for change was described as a key component to the type of attitude that benefits court-mandated parents. This statement embodies that attitude:
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“What they did was purposeful at the time they did it. They got so angry or whatever and they had no other internal resources to rely on. But they never woke up saying, ‘I’m going to hurt my child.’” To maintain a positive attitude, participants focused on the following: good results with parents; the role of their efforts in keeping children safe; and the sense of mission that originally drove them into the work. As one participant said, “It wasn’t just about schlepping here and there and dealing with foster parents, dealing with natural parents, dealing with the court system. You are actually treating these children. That made a big impression on me.” Some drew on their own childhood backgrounds to help them in the clinical work. A few people in the study had parents who worked in various capacities with people encountering trouble. These participants credited this early exposure to the unseen fabric of American life, which gave them a sensitivity to help parents wishing to retain or regain child custody. I think my dad [a police officer] was in the juvenile division. He was a sergeant for a long time. You would hear stories, and I saw how he worked with people. He taught us that people always deserve a chance. Another therapist explained the impact of positivity in early life, saying, “I grew up believing that people could change, if people were treated with respect and dignity. That was one of the things they needed to be able to make changes in their life.” Others described how a healthy family background provided them with a strong reference point, as this participant explained:
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I came from a good family life. That did help, and I really benefited from two good parents. I was the youngest of a sibling group, and we were a really strong family. That helped. I kind of knew what healthy families could be and should be. Understanding that the work of becoming a good parent is done by the client and not the therapist was described as an important realization that helped therapists maintain a positive attitude. Laying the responsibility for change fully with the client helped some in the study hang onto their positive regard for clients. I think the biggest turning point for me was, “You don’t have to save people. You just have to help give them the tools.” They run with it or they don’t. You help them by giving them tools, and then they decide.” This positive attitude―based on allowing people to make mistakes and learn from them―developed in different ways for different therapists, but everyone in the study demonstrated it during their work, and described it as helpful in clinical encounters.
Personality type. Participants believed they were well-suited for this type of clinical work because of their personalities. Some felt they were constitutionally equipped to handle the intense feelings that accompany work with court-mandated parents. Others said they were practical and had an ability to compartmentalize. Still others noted their capacity to stay calm during a crisis. Although they described different personality traits, all therapists agreed that having a personality suited to working in this clinical environment aided their successes.
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“I think it is part of my own personal coping style,” one therapist said, describing strategies for dealing with volatile situations. “I go into this mode. I get calm, controlled. I have this ability to just sit with that, and see what other people’s needs are. It’s much later that I’m like, ‘Wow, that was really scary.’” The sense of having an appropriate personality for the work was strong. Some therapists even claimed an ability to sense its absence in fledgling social workers. I also think there is a personal constitutional temperament, personality type, that is related to this. I am sure you have encountered it in people. You think to yourself, “Why are you a therapist? Why is he a CPS worker? What are you doing in this field?” This might be terrible to say, but perhaps you feel, while working in a school setting where you are teaching new social workers, “Why are you in my school? You should not be a social worker. You don’t care enough.” I think that’s just true.
Self-care. Participants understood that working clinically with mandated clients can be emotionally draining. That realization provided the first step in developing a self-care plan. Everyone had a different way of describing their self-care strategy, but all said they benefitted from self-care. Some had a definite daily routine, such as exercising, socializing, and time for reflection. Others were more spontaneous and relied on self-care only when overwhelmed by the work. Everyone understood that having a plan made them more available to their clients, family, and friends. “I think self-care is extremely important,” one participant said. “We can’t assume what’s going to be helpful for everybody. I have my people that I like to call. I have the
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things I like to do, that are meaningful to me.” Another therapist said, “For me, exercising was good because I felt good about myself, and when I felt good about myself I was able to feel confident.” Getting a pedicure, running, cleaning the house―participants named all these activities as self-care. One even mentioned watching the Lifetime channel, which is notorious for its melodramatic made-for-TV movies about women in trouble. “I’m like, ‘See? That does happen.’” For many in the study, the effectiveness of self-care reflects in their work experience. I know that I am giving myself good self-care when I am OK with people being in a closed room and having a meeting without me. I can go in and share details or present assessments and be confident with the assessment and my recommendations, but also (be) open to hearing when other people have feedback. (They’re) not being critical. Feedback is just feedback. Not getting defensive. That is how I know I’m giving myself good self-care, because when I’m not giving myself good care that all just implodes. I really have to check myself, and that again is where the boundaries come into place. Some reported that their ability to continue the work over the years depended on these factors: (a) recognizing that the work is difficult, (b) implementing good boundaries, and (c) developing self-care strategies. “Thirty-seven years I never felt burnout,” one therapist said. “Sometimes you have to keep your professional life in a place and then your other life (in another place).” This kind of compartmentalization provided a common theme in research interviews. My supervisor told me to leave it at the door, not take it home with me. I had about a 45minute commute. I would mentally prepare myself on the way there and then kind of
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think about it on the way home. I would tell myself, “I am just going to think about it on the way home and then be done with it.” Another participant described the importance of boundaries: My life is what I care about. I am a facilitator to help them through their life, so my mindset is not about caring. My mindset is: They are coming to me to provide a service and these are the goals that they want to accomplish, so my job is to help them accomplish those goals. I don’t emotionally invest a lot of energy into that. I used to do that and that’s where I got burned out. Several research participants talked about how their personal self-care plans not only helped them do the clinical work more effectively, but also helped them be better parents. I work out every evening, even when I really, really don’t want to because I know it’s going to help me get the stress out. If not, I know it’s going to come out on my kids. I am short-tempered or frustrated when I get home because I had a day filled with short-tempered frustration aimed at me. I’ve got nowhere else to put it right away. Sometimes I get home, and I’m not as loving and compassionate as I usually would be. I don’t want to explore anything with my kids when I get home because I am done for. I am beyond. Another therapist explained the work / family dynamic like this: I could’ve been resentful (about a work issue), but at the end of the day that doesn’t help my daughter. It doesn’t help my clients, and it definitely doesn’t help me. So, it is just being able to look at how you take care of yourself. The people closest to you are the ones that get burnt out (when you are in) emotional burnout. That is what I started to understand.
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In addition to working out or exercising, some participants engaged in more calming forms of self-care. I do pray and I try to meditate, but I’m not very good at sitting still. I try to at least take a few minutes to take some deep breaths and make sure that I’m keeping myself calm. Some days you feel like you’re just running back to back to back. Taking a few minutes to meditate (is helpful). Nutrition is a big part of it. If I’m not eating well, I will get angry and that’s never good for anybody. It’s being able to make sure that I am just taking care of even my most basic needs. Self-care helps therapists be better parents, but children can also directly figure into self-care strategies. “I try to laugh with them and enjoy them and rock them,” one therapist said about her children. “Even though it’s not their job to give me self-care, enjoying that relationship gives me the self-care that is helpful.” Learning to balance home life with this type of clinical work was challenging for those in the study, but not insurmountable. For some, spiritual belief reduced the work’s emotional toll. Spiritual connection, combined with a solid education, was credited for the ability to work with confidence and passion. Having a solid spiritual foundation, and being able to the use that and pair that with empirically supported treatment and therapy is important. Having that mix together toward the client, because every client is different. I have to know different theories so I can use those systems in order to work with my families. I use those theoretical foundations to work with my individuals. If I don’t know them, I don’t know what tool to pull out of my toolbox. When I see a particular
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situation in front of me, I can’t use a hammer for everything, and you cannot use a wrench for everything. You have to pull out specific things. Participants discussed a variety of definitions for “self-care.” No two people defined it the same, but everyone agreed to its importance for reducing the negative impact of the work.
Supervision. When asked about what prepared and sustained them for working with courtmandated parents, most participants said, “supervision.” They described it as one of the most helpful professional resources. A supervisor who was available to talk through difficult cases provided the safe space for the therapist to “vent.” Most in the study had good supervisors who provided this space, which proved beneficial even when not needed. As one participant said, “The fact that it is there, and you know it is there, and you have an opportunity to make sense of things is meaningful.” On the other hand, poor supervision did not help the therapist learn and grow in the craft. You knew who you could talk to. There were a few people who were not so supportive. You knew who they were early on, and you kind of avoided them or gave them just enough info to keep them in the loop. But [you didn’t] really respect what they told you. I was lucky; those were few and far between. I think I only had that one guy that was a really poor supervisor. We just didn’t click. He was punitive.
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When good supervision was not readily available, therapists sought the counsel of colleagues and peers. One participant described the bond that exists within a tight-knit professional community: “The fact that we were able to help support one another in a very close way was really meaningful. These people were there with you when something terrible happened.” Most therapists in this study had excellent supervision. Those early in their careers found it especially important to have a supportive leader for guidance and direction. “Our direct boss was a very wonderful man,” one participant remembered. “He expected a lot from us, and I learned a lot from him. He was very supportive. You would have supervision, and you thought you came out of a therapy session.” Another participant remembered supervisory sessions not just as “venting,” but collaboration. She had been around for a while. At the time, she was probably only in her thirties, but she seemed so much older and wiser. It was really helpful. It was informal, but somebody you could really talk to. She would bounce ideas off you, like, “Why don’t you try this?” As stated in another interview: “[You need] a good supervisor to trust you, to kind have faith in you. You can say, ‘Here’s what I did. What do you think about that?’” The idea of supervisors providing sage counsel was echoed in another interview: “Yes, it’s very important, especially as a new person. You need to know people who have been there, and who have been through the same issues, because they are pretty universal.” Elsewhere, the importance of good supervision intersected with the concept of self-care: “The self-care of figuring out when I need help and going to the people I know
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will help me, whether that’s in the professional realm with the supervisors or peers, or sometimes from my spouse or my parents” In addition to providing insights and advice, supervisors’ willingness to listen proved essential. I’m really concerned about this kid. Even to say, “I don’t know what else to do,” that’s important, and feels safe. To not have that person say, “You don’t know what you’re doing.” As long as I can go and say, I don’t know what I’m doing. What do I do next? I’m kind of lost here.” The work can take a toll on the therapist but good supervision provides relief. Being able to be completely transparent about the difficulties of working with this client population was important for personal well-being, as well as learning how to better help clients and their families. Participants talked enthusiastically about supervisors and their impact, both personally and professionally. One person summed the importance of supervision like this: I think the biggest thing for being effective in this field is having a good support structure and the good supervisor. I’ve had good supervisors and I’ve had bad supervisors. I have to tell you, my overall contentment with the job is related to the kind of supervision I’m getting at the time.
Peer / colleague support. Along with good supervision, peer / colleague consultation and support helped therapists minimize the emotional toll of the work. When discussing a case that was particularly challenging, one participant said, “So, that peer supervision is really
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valuable.” Another therapist expressed her opinion about the support of peers as, “Very helpful―I couldn’t get by without colleagues.” Peer relationships helped sustain therapists and brought them back to the work, day after day. Someone who understands the work and provides unconditional support, even when emotions run high, makes a big difference for those working with this difficult population. Colleague support often proved invaluable. It helped minimize the impact of sitting with and listening to traumatized people. It was like there were no words to be said about what was happening. We were all horrified. We were deeply grieved by what was happening. That was one of those salient moments where I felt that presence of a team of people. We met together several times to sort of provide support to one another. Another therapist described group meetings as not only supportive, but strategic. We had all these networking meetings. We were always together. We would do a case staffing on this family that everybody and their brother was involved with. We would have like 20 people there, trying to figure out what we were going to do with this family. That made a big difference. Having the ear of people who understand the work and know the related stress helps minimize the impact. A lot of it was just the support. Working with each other was critical. Our colleagues, we were all young, all single. Team meetings were usually sitting around a pitcher of beer, [talking about] what happened in our day. Of course, we didn’t use people’s names or anything. Just to have that support of colleagues that were doing the same work and could understand. Some of the more seasoned
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workers mentored us younger workers. [The work is] not something you can talk to a lot of people about. They just don’t get it sometimes. The support of empathetic colleagues can minimize the emotional toll of the work. One participant said, “If it had not been for the colleagues and the support we had from each other, we might not have made it as long as we all did.” Another said, “You have to have somebody to bounce things off, to vent.” Most participants mentioned the value of peer support at least once. “One of the nice things about being in an agency is that there is still confidentiality, but you have that ability to staff cases in a more direct manner,” one participant said. “You are able to vent and process.” This ability helped therapists manage the emotional rollercoaster that can sometimes occur while working with court-mandated parents. Sometimes we just call each other on the phone. Our favorite thing to say is, “Do you have two minutes?” It is never two minutes. It is an hour and a half or 50 minutes. “Two minutes” is the code word [for] “I seriously need to talk to somebody and if I don’t it could get worse.” The peer-support dynamic engendered a feeling of solidarity. “There were two of us for the same family,” one therapist remembered. “Then we had a supervisor we would meet with once a week. You didn’t feel like you were by yourself.” Another participant shared a similar perspective, saying, “The people I worked with in that program, we became pretty close and we were able to really talk about our feelings about these different cases.” Lastly, a participant said that peer support “was extremely valuable, not only for that (particular instance), but just becoming a clinical social worker in general. I continue to consult with them, even about personal issues.”
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The support of colleagues can provide a valuable tool to ward off burnout. Many in the study credited their colleagues with helping their professional development and career longevity. The therapists in this study agreed working clinically with parents seeking to retain or regain custody of their children can be challenging and emotionally taxing. They described the many factors that contribute to the difficulty, including: 1. Being a new therapist … 2. Dealing with life and death situations … 3. The personal nature of the work … 4. Carrying the work home … 5. Feeling responsible for custody decisions … 6. Knowing that being reported to CPS could happen to any parent … Learning to manage the emotional hazards is required for working in the field long term and staying fresh with clients. Additional contributors managing the toll of the work include: 1. Having a faith, mission or passion 2. Possessing an attitude or personality style suited to the work 3. Good self-care strategy 4. Good supportive supervision 5. Peer/colleague support
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CHAPTER IX
Findings and Implications Overview Chapter Nine contains the following: 1. Review of the purpose of the study and the research question 2. Summary of my process 3. Discussion of major findings 4. Implications for policy and practice 5. Limitations of qualitative research 6. Suggestions for future research 7. What I learned through the process of completing this study
Purpose. The purpose of this grounded-theory study was to develop an understanding of the clinical experiences of clinical social workers working with parents who have lost, or are threatened with loss, of child custody. Sixteen therapists were interviewed. All had worked with this client population sometime during their career. Most continue to see parents in this circumstance. More than 500,000 children in the United States reside in out-of-home placement (Administration for Children and Families, 2013). The parents of these children are often referred for therapy by the state’s child-protection and foster-care
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caseworkers. The experiences of these therapists in the clinical setting are the subject of this research.
Research Question. “Facets of involuntary parent-child separation: A clinical social work perspective” is the research question explored with this group of 16 therapists. Open-ended questions, along with prompts, provided an in-depth exploration of therapists’ experiences in clinical work with parents seeking to retain or regain child custody.
My Process. I distributed invitations to participate in the study at clinics and private-practice settings. Individuals contacted me via phone or email, and requested to participate. I sent consent forms via email, prior to interviews, to ensure that participants understood the study. Interviews were arranged at participants’ convenience at a private location of their choosing. Interviews were audio recorded for later transcribing. Grounded-theory coding was conducted and four major themes emerged: 1.
The fabric of American life no one wants to talk about
2.
The work is hard and evokes many emotions
3.
Interference in the clinical encounter
4.
The work can take a toll on the therapist and must be managed
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Brief Description of Findings Finding One: The fabric of American life no one wants to talk about. Therapists working clinically with abusive and neglectful parents hear stories about trauma and abuse every day. Most Americans don’t know the degree to which it occurs and don’t want to know. It is too emotionally toxic for most people to digest. These therapists hear about the horror every day and must find a place to deposit the images that invade their awareness. Talking about trauma in a safe setting, where someone understands and empathizes, can be a powerful tool for healing. But when the therapist cannot share the traumatic stories because of ethical considerations and legal obligations, or because non-therapists cannot handle the details, these stories can become internalized and create a vicarious trauma. This group of therapists described the reality of trauma in American life and the refusal by many outside the field of social work to acknowledge or believe that it is real.
Finding Two: The work is hard and evokes a variety of .feelings Participants in the study agreed the clinical work with parents seeking to retain or regain custody of their children is hard and evokes many emotions. This theme describes the core results of this study. Therapists reported experiencing a range of emotions, which made the work hard but at times rewarding. These emotions included: 1. Hopeful 2. Anxious 3. Sad 4. Traumatized
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5. Conflicted 6. Angry 7. Inadequate 8. Powerless 9. Disappointed 10. Worried 11. Frustrated 12. Heartbroken 13. Heavy 14. Guilty 15. Stressful 16. Disheartened
Finding Three: Interference in the clinical encounter. Working clinically with parents accused of abusing or neglecting their children can present challenges not experienced with other types of cases. Participants received referrals from mandating agencies, usually the local child-welfare organization. Working with mandated clients― under pressure from a system poised to permanently remove children from parent’s care―can create a clinical experience ripe with interference. Staying focused on the client in the room, keeping transference and countertransference reactions at bay, and seeking to minimize the “presence” of the mandating agency (and the abused and neglected children) can present a challenging clinical encounter. This
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group of therapists described the interference and how they worked to focus on the clinical needs of their clients.
Finding Four: The work can take a toll on the therapist and must be managed. Therapists in this study agreed that the work is hard and can take an emotional toll on the therapist. The following situations create stress and must be managed: 1. Being a new therapist 2. Dealing with life and death situations 3. Feeling the work is personal and carrying it home 4. Feeling responsible for custody decisions 5. Knowing CPS could be called on anyone Participants shared how they learned to manage these difficulties, to mitigate their negative influence. These management tools included (a) having faith, a mission, or passion, (b) possessing an attitude or personality style suited to this work, and (c) having a rigorous self-care strategy, coupled with good supervisor and peer support.
Clinical Implications Finding One: The fabric of American life no one wants to talk about. Pearlman and MacIan captured the essence of this first finding: It is not difficult to understand the loss of esteem for others as individuals are exposed, perhaps for the first time, to the horrors of people’s capacity for cruel behavior against others. That which formerly may have been defended against can no longer remain unknown, unseen. (1995, p. 564)
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Trauma workers have a unique perspective on the world. Vicarious trauma develops over time with repeated exposure to trauma stories, and while sitting clinically with traumatized people (Adams & Riggs, 2008, p. 26). It can accumulate over time, and if not addressed adequately, it can cause psychological damage to the therapist. In their book, Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others, Lipsky and Burke describe what can occur when trauma goes unprocessed: After so many years of hearing stories of abuse, death, tragic accidents, and unhappiness; of seeing photos of crime scenes, missing children, and deported loved ones; and of visiting the homes of those I was trying to help - in other words, of bearing witness to others’ suffering – I finally came to understand that my exposure to other people’s trauma had changed me on a fundamental level. (2009, p. 2) Participants in this study shared stories of working clinically with trauma. These stories described the fabric to American life that many outside the helping professions don’t understand and don’t wish to understand. It is too emotionally noxious for the average person to comprehend. Results of the study confirm therapists working with trauma know a side to life that others do not. As one therapist said, “When I began that work, I thought to myself, ‘Oh there couldn’t be that many cases in (my county). Maybe there are five families where this should happen. It kind of surprised me that there were so many.” As quoted in Chapter Five, another participant said: When I talk about it with my mom or my nuclear family, they don’t have an idea what is going on. They are always surprised and, “Oh my gosh, I can’t believe
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that people do that,” or, “I can’t believe that this happens,” and I will kind of say, “You know, it happens a lot more than you think.” Every year more than 500,000 children are traumatized by their parents and guardians (Administration for Children and Families, 2013), and fall under the watchful eye of the child-welfare system. More than 80% of the perpetrators are the parents (CDC, 2014). The remaining percentage includes relatives or unmarried partners of the parents. Child neglect includes failure to provide adequate physical, emotional, medical, and educational care―along with inadequate supervision and exposing children to violence. Physical abuse is defined as the intentional use of force that results in harm to the child (CDC, 2008-definitions document). In 2012, the CDC estimated that 3.4 million reports of child abuse were made to child protection agencies (CPS). Of those reports, more than 600,000 children were deemed as “maltreated” (CDC Fact Sheet, 2014). Many factors contribute to parents abusing their children, and the research has been unsuccessful in isolating a single cause (Haskett, Scot, & Ward 2004). Participants attributed their desire to help others as the impetus for a career in social work or counseling. Some specifically wanted to help children. Social workers “are often deeply connected to their work” (Radey & Figley, 2007, p. 207), and these deep connections can be useful when working with abusive parents. However, these connections can also create problems for the therapist, including undue stress. The scope of this study did not allow time to explore personal issues with abuse and neglect. However, during interviews, some therapists reported being reminded of their past when working with their clients. During home-based clinical work, some
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participants were reminded of their own personal issues with trauma. As one therapist said, “Some of the houses could trigger emotions. Now after doing it for 15 years, I have kind of worked through that.” Finding a therapist who could help process personal trauma helped participants, and allowed for greater connection with clients. When therapists worked through their personal struggles, they were better able to recognize and examine clients’ defenses. Most participants did not use the language of psychodynamic theory, but everyone understood the concepts. I walk into those homes, where he gets away with stuff. Then I am looking for their defensive techniques and my psychoanalysis brain says to look for what they are projecting and how they are wording things. So, (in) a lot of this, I will say, “Hmm, let me see how this works out.” “Compassion is an essential element in effective direct social work practice” (Radey & Figley, 2007, p. 207). To connect with clients and give them the optimal environment conducive to change, the therapist engages in an empathetic relationship that, if not supported properly, can lead to compassion fatigue (Radey & Figley, 2007, p. 207). Adams and Riggs (2008) discussed the cumulative effect of hearing stories of trauma, specifically how the inner experience of the therapist transform, creating vicarious trauma. This results from empathic engagement with traumatized people (p. 26). The literature makes clear that unresolved stress places therapists in danger of losing their ability to empathize, burning out, and eventually leaving the field altogether (Adams & Riggs, 2007, p. 27). Participants expressed their own experiences with feeling “unhinged” when hearing stories of abuse. As quoted in the “Results” section: “It was almost like a vicarious trauma for me.”
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Therapists who work with child-abuse perpetrators commonly understand the intergenerational transmission of abuse. Parents abused as children into adolescence are more likely to perpetrate child maltreatment, as compared to parents not abused in their youth (Thornberry & Henry, 2013, p. 564). The weight of knowing the generational effect of child abuse gives urgency to the clinical encounter. Awareness of trauma and its prevalence in our communities carries with it a responsibility that others do not share. Learning to manage the negative impact that comes with engaging empathically with traumatized individuals and perpetrators is essential for therapist longevity in this field. Participants were fully aware of the hazards their work presented. They learned to manage it and some got out before it became overwhelming. As quoted in Chapter Eight: “It was like there were no words to be said about what was happening. We were all horrified. We were deeply grieved by what was happening.” Participants firmly understood the fabric of American life that includes child trauma. Many also felt that non-clinicians in their lives remained willfully ignorant of child trauma. These therapists found people who were aware. Participants regarded a safe space to share with a compassionate listener as a powerful resource for managing vicarious trauma. Experiencing trauma or hearing about the trauma of others can alter a person’s worldview (Janoff-Bulman, 1989). Most therapists enter the field without full knowledge of the harsh realities of human cruelty (Canfield, 2005). Canfield suggests trauma workers should be “warned” that empathic engagement with traumatized people can alter the inner world of the therapist (Canfield, 2005, p.88). Results of this study confirm that
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the work can alter the therapist’s worldview. As stated in Chapter Five: “I realize that my perspective is kind of skewed. Sometimes when I’m talking to somebody, their eyes get glazed, and bigger and bigger. It’s like, “OK, let’s talk about something else.” Trauma workers, with their unique perspective on the world, provide a safe space for clients to heal and grow, offloading unwanted feelings. Seeking counsel from supervisors, developing healthy relationships with colleagues, and maintaining a strategy for self-care all contribute to warding off the ill effects of vicarious trauma.
Finding Two: The work is hard and evokes a variety of feelings. Sources of stress for participants included: 1. Case overload 2. Limited resources 3. Conflict with the referring agency 4. Long hours 5. Low pay 6. Heavy caseloads Stories can help the stressed worker make sense of work experiences (van Heugten, 2011, p. 126). A poster that includes the revised and shortened version of “The Star Thrower” story by Loren Eiseley (1978) hangs on the wall of my office. I was so taken with its metaphor that I had the poster professionally framed so everyone could share in its uplifting message of the little boy walking the beachfront after a storm, throwing starfish back into the sea. Because the storm had washed thousands of starfish ashore, making it impossible to get even a quarter of them back into the sea, a passerby asks the
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young child why he bothers because it certainly does not make a difference. The child, holding a starfish, replies that it makes a difference to “this one,” and throws it into the sea. The message: Even though many are in need, and one innocent little boy may not have the capacity to help everyone, even by helping one he does good. There is hope in the world. Clinical social workers need to feel that their work has value and benefits clients. This helps “maintain a sense of a competently functioning professional self” (van Heugten, 2011, p. 128). Bringing the “instrument of self” (Black & Weinreich, 2001, p. 25) to the clinical encounter requires that social workers thoroughly understand themselves, the good and not-so-good alike. My proud display of the edited version of Eiseley’s “Star Thrower” takes on new meaning as I now understand that the “thrower” was not a young boy, but an old man weathered by years much like myself. After more than 25 years of engaging in empathic encounters with traumatized people, I desperately want to believe my work has meaning to someone. As I listened to the participants, I resonated with their experiences. I had found kindred spirits engaging in work that is hard but rewarding. We have our own community with shared language. Our experiences provide both positive and negative consequences. Finding each other makes the work more meaningful and wards against feelings of isolation. We are connected again with our original self-object. We can return to the “hard” work every day. Participants in the study described their work with abusive and neglectful parents mandated to treatment as “hard.” All agreed that a variety of emotions formed the
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landscape of clinical encounters. These emotions are the “feeling words� they used to describe their experiences: 1. Hard 2. Hope 3. Anxious 4. Sad 5. Traumatized 6. Conflicted 7. Angry 8. Inadequate 9. Powerless 10. Disappointing 11. Worry 12. Frustrating 13. Heartbreaking 14. Heavy 15. Guilty 16. Stressful 17. Disheartening This finding represents the core results of this study. Participants reported that recognizing these feelings, and sharing them with supervisors or peers, was most helpful in warding off their potential negative impact.
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When therapists assure clients that life can improve after treatment, it can empower parents seeking to retain or regain child custody. These parents often come to the clinic having been battered by an apparently unsupportive system. Generating hope in therapyoutcome expectations can enhance the possibility for change (Swift & Derthick, 2013, p. 284). Participants described feeling hopeful that their clients could change and keep their children safe. Therapists tried to pass on those feelings of hopefulness because they understood the importance of feeling positive about the clinical work. In Chapter Six, a participant said, “You never know but you hope. So sometimes it’s the cases where you don’t really think anything happened that maybe a lot of things did happen for them.” Also from that chapter: What also brings you back is that she (mom) has a positive attitude about it. I have watched her demonstrate that (attitude) in some very difficult situations. So, if you’re willing to go again and keep facing this head on―I realize it’s not close, it’s not easy―I will go with you. I will support you in that. Participants described how they learned to continue being optimistic about courtmandated clients, even when other professionals had given up on them. Here I am sitting with my client face-to-face on a weekly basis, and I am rooting for her. I am like, “You are showing up. You are doing your treatment plan. We are doing treatment plan reviews. You are making me feel really good about my job. You are making me feel like the clinician I’m supposed to be, and all of my schooling and everything. Me being present here with you, we are jiving right. We are good.” So, I feel really good as a clinician.
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Our emotions prominently factor in how we operate in the world. They impact our daily living and relationships with others. They shape our sense of self, impact how we form relationships, and influence who we feel safe with and in what contexts (Porges in Fosha, Siegel, & Solomon, 2009, p. 27). When daily work evokes a variety of emotions, the situation requires special attention to the presence and regulation of those emotions. Recognizing the feelings evoked by abusive or neglectful parents is the first step in learning to manage those feelings. Therapists in this study readily acknowledged the many feelings they felt during the course of the day. As a participant said in Chapter Six, “There isn’t an emotion out there that you don’t feel. Yes, there’s a lot of them. There’s a lot of them.” Also from that chapter, a participant said, “I just felt like not enough, like I didn’t have enough experience or I wasn’t a parent,” while another reported, “There is a little feeling of helplessness and trauma that comes along with it, because you’re hearing about things that have happened to children.” Reports of troubling emotions continued into Chapter Seven, when a therapist said, “(It’s) not only, “How can the parents be like this?” It’s also, “Why doesn’t someone protect these children?” Staying fresh for clinical encounters demands the recognition of emotions and awareness of vicarious trauma as a professional hazard. Karen Saakvitne (2002) urges therapists to stay aware by regularly asking themselves, “How am I doing?” As we assess our own psychological health and well-being, we need to consider strategies of selfprotection and healing that can support us as therapists and diminish the negative impact of our work. (p. 447)
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The multiple emotions that get evoked can work against the therapist, even to the extent of creating vicarious trauma. In her 2002 article, “Shared trauma: The therapist’s increased vulnerability,” Saakvitne talks about the need to “escape” from the barrage of emotions related to working with traumatized people. In particular, she makes reference to the need for community. Communities offer connection with shared visions, beliefs, hopes, dreams, and goals―thereby transform the existential isolation associated with despair and grief. Communities speak to the potential creativity and constructive outcomes that result when humans work together to bring about positive change. (p. 448) Participants described finding community with their supervisors and peers. In Chapter Five, one therapist said, “I would just pick up the phone and call them and I would cry and just say, ‘This is terrible.’” In that same chapter, another therapist described talking to a loved one: “I will run stuff by him, because he knows. So I say, ‘So I’m not crazy?” and he will go, ‘No, you’re not crazy.’” Later, in Chapter Eight, a participant talked about peer and supervisory interactions, saying, “Yes, it’s very important, especially as a new person. You need to know people who have been there, and who have been through the same issues, because they are pretty universal.” One participant described how a supervisor helped during a particularly difficult case that required the therapist to accompany a client to the hospital: That night I called my supervisor because I actually followed them to the hospital. They were admitting (a client) that night and she asked me to come. So, I processed it with my supervisor on the way there to the hospital.
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The support of supervision can help therapists wrestle with the many emotions they feel while working clinically with this difficult population. Participants credited supervisors with providing space to vent, although colleagues could also help in this regard. I did have a lot of support from my team when I was working on that case with my immediate supervisor and my closest colleague. I would just pick up the phone and call them when I left the house because of how crappy I felt. Collegial support is essential for those working with trauma (Miller, 2003). When working with traumatized clients and those who traumatize others, the “experiences and reactions of patients can ‘rub off’ on the therapist” (Miller, 1998, p. 137). In addition to talking about feelings evoked by the work, the therapist needs a place to grapple with the cause of the trauma. An “intellectual understanding” of why trauma occurred can help in the debriefing process (Miller, 1998, p. 143). Participants reported that they seek out colleagues to explore the emotional content of clinical work, specifically to understand why people do horrible things to each other. From Chapter Four: Me and other clinicians talk all the time about what we are going through and how can we make it better, or how can we make it more streamlined so we don’t feel so overwhelmed or sad or bogged down. Encountering trauma in everyday American life is highly likely, but for certain populations, the rate increases. These are the populations that social workers are more likely to serve (Bride, 2007). Doing clinical work has the potential of having a “negative emotional and psychological impact on therapists” (Macchi, Johnson, & Durtschi, 2014,
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p. 380). This is compounded when clients are trauma survivors and tell stories about their experiences. Feelings get evoked in the therapist and must be managed. The literature on vicarious trauma, secondary traumatic stress, and burnout confirm that a supportive supervisor or colleagues can help ward off negative effects (Canfield, 2005, Linley & Stephen, 2007, Macchi, Johnson, & Durtsci, 2014). Results of this study confirm the powerful impact that supervision and peer support can provide in the offloading of overwhelming emotions. In Chapter Five, a therapist said, “I think that’s more valuable than anything, supervision, just the ability to express how this affects me,” and in Chapter Eight, another participant said, “The fact that we were able to help support one another in a very close way was really meaningful. These people were there with you when something terrible happened.” Whether it is feeling overwhelmed, inadequate, sad, hopeful, disappointed, traumatized, or angry, all therapists agreed the work is hard and evokes a variety of emotions. Supervisors provided invaluable support. Trusted colleagues and friends also provided a space where feelings could be expressed, and the potential for any negative emotional effects could be lessened.
Finding Three: Interference in the clinical encounter. The quality of the client-therapist relationship, scholars generally agree, is that the most important predictor of positive client-treatment outcomes (Manchak, Skeem, & Rook, 2014). The therapeutic relationship between client and therapist is a “working alliance founded on trust, openness, genuineness, and congruence” (Honea-Boles & Griffin, 2001, p.150). Connecting on a deep level is vital if parents are to heal and stop
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hurting their children. This type of connection also creates an environment where transference and countertransference can interfere with quality treatment. Therapists in this study acknowledged that clinical encounters include the ongoing presence of the mandating agency, as well as clients’ children. Having “four people in the room” can create an environment with heavy interference. Results of the study indicate that participants had an awareness of this potential chaos. “I try to focus on the person in front of me, to serve them and their needs,” one therapist said. “They definitely always have some trauma, no matter what the situation.” Empathic engagement can enhance clients’ ability to change their personality and behavior. “It is one of the most delicate and powerful ways we have of using ourselves” (Rogers, 1975, p. 2). Opening oneself up to empathic connection requires the therapist to connect without prejudice (Rogers, 1975). While this level of connection leads to successful clinical work, it can also create problems. For instance, when the client is mandated by a state child-welfare agency and children have been abused or neglected or both, this type of connection can be difficult at best. The “voices” of abused and neglected children can carry into the clinical encounter. Therapists understand the long-term consequences of child abuse and neglect, which keeps professionals on edge and highly motivated to help end the abuse. All participants expressed a commitment to child wellbeing and protection. In Chapter Seven, a therapist said, “I just feel like people get into social work for different reasons but mostly because you want to help people. I always loved kids and I always wanted to make a difference.” Also in that chapter, a participant said, “It was difficult because I sympathize more with
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the children. Sometimes it’s hard to watch and think, ‘How could you have done this to your kids, or in front of your kids?’” Study results confirmed the need to acknowledge and manage interference in the clinical encounter. The presence of abused and neglected children can be felt in the clinical encounter with parents, which creates a unique set of problems for the therapist to overcome.
The System. The child-welfare system can be a loud “voice” in the room and cause intrusion in the building of a therapeutic alliance. Clients mandated for treatment through the childwelfare system generally come into therapy with prior exposure to the system that referred them. The results confirmed those interactions were almost always negative. A therapist said, “Sometimes I think systems set people up because they don’t tell the parents things they needed to know before they go to court.” Another participant put it this way: Systems don’t help the parent, and they are not treated fairly. There is no consistency in any of these systems, so one parent can do one thing and not be held accountable, and another family held accountable and get in trouble for doing certain things. The negative relationship between clients and referring agencies can spill over into the nascent client-therapist relationship. Therapists are required to write reports on treatment progress, which can confuse clients into thinking the therapist is too closely aligned with “the system.” Participants took extra steps to minimize this confusion by warning parents
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when calls to Child Protective Services were required or even having the parent make the call. Reading reports to clients before they were submitted also cleared up misconceptions. “I would always review my reports with the client before I would go to court, so it would never be a surprise to them,” one participant said. Another therapist went into more detail: I would always spend time talking with them about why I said the things I did in the report and what it meant beforehand. I always have the idea of the relationship with a client in the forefront, because the relationship is going to be the vehicle for change. Making clear explanations of the role of the therapist versus the role of the mandating agency helped these therapists clear the room of potential interference from “the system.”
Transference and countertransference. As partners in the clinical work, the client and therapist connect and have an impact on each other. In this two-person psychology, “clients and clinicians are viewed as partners who co-construct the treatment process” (Miehls, 2010, p. 370). Parents seeking to retain or regain custody of their children present unique opportunities for transference and countertransference. In addition, there is the potential for enactments. Although study participants generally did not use the language of psychodynamic theory, they described situations that speak to enactment dynamics. In Chapter Seven: If it is an issue that keeps coming up, I need to take care of it outside of supervision. Maybe once or twice is not an issue, but if you are having it on a monthly basis or something, and you are making choices based off of emotions, I
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think supervision can only go so far. Supervisors are not meant to manage emotions. They are meant to help you figure out how to manage your emotions. Originally Freud considered countertransference as a hindrance to clinical work (Freud, 1915). Much has been written on the topic by a wide range of theorists during the past century. In the two-person treatment model, countertransference can be a useful tool if handled appropriately. Adshead, Paz, King, and Tagg (2010) describe their grouptherapy work with abusive parents. The researchers found that the group “conductors” had countertransference reactions while leading group intervention. “These feelings may be understood as effective countertransference, and highlighted the risks of getting alongside minds containing cruel and fatal thoughts.” (Adshead et.al., 2010, p. 210) In general, clients recognized and worked through their countertransference reactions to clients. They usually described the countertransference as “feelings.” Most did not use the language of psychodynamic theory, making it difficult to know if they were able to use the countertransference to further the treatment. Countertransference was mostly described as something to manage. From Chapter Seven: I have spent some time reflecting on why is it so hard for me when he (family member) does things that make me crazy, and why do I give people I work with so much slack when they are kind of engaging in the same thing a lot of times. It is because the people I am working with are working with me. They have some inkling that they would like me to help them with something. In the same chapter, a therapist said, “Some of the houses could trigger emotions. Now after doing it for 15 years, I have kind of worked through that.”
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A solid therapeutic alliance depends on the therapist’s ability to manage countertransference. Clearing the treatment room of “voices” from the abused and neglected children was one of the more difficult tasks. When therapists explained to clients that the role of therapist differed from that of the mandating agency, it diminished the presence of “the system” in the room.
Finding Four: The personal toll of the work and how to manage it. Bearing witness to the trauma of others has the potential to impact the therapist in a profoundly negative way. It is generally understood that a compassionate, empathic therapist risks developing secondary traumatic stress, vicarious trauma, compassion fatigue, or burnout. Prolonged exposure to stories of suffering can take a toll on the therapist. If they are to continue doing the work, they must develop a strategy for selfcare. This strategy should include an honest appraisal of self, and a rigorous exploration and implementation of activities that will reduce negative psychological reactions. Results of the study confirm the work has the potential to take a toll on the therapist. As we heard in Chapter Eight, “It takes a toll on you. You really question who you are, what you have to offer. (You wonder), ‘Am I hurting someone?’ That is the last thing that you want to do. That is not why you got into this.” Many factors make the work difficult. Participants called out the following: 1. Dealing with life-and-death matters 2. Doing deeply personal work 3. Feeling responsible for custody decisions 4. Being an imperfect parent
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Once therapists acknowledged these difficulties, they could manage them. Saakvitne (2002, p. 447) warns us to stay aware of signs of vicarious trauma, and to develop a good balance between work and leisure. Participants explored a variety of ways to manage the toll of this type of clinical work, including: 1. A passion for helping others 2. A personality type or attitude that suited this type of clinical work 3. Support of supervisors and peers 4. A solid strategy for self-care Empathic engagement with clients is warranted when working with abusive parents. But listening to clients’ stories can leave the therapist open to compassion fatigue or vicarious trauma. With prolonged exposure, burnout becomes a possibility. Yet good things can happen as well. Saakvitne (2002) warns against becoming “jaded” (p. 448). Working with a group of people can counteract negativity, while helping the therapist stay connected with traumatized clients.
Definitions: Secondary Traumatic Stress, Vicarious Trauma, Compassion Fatigue, and Burnout Secondary traumatic stress, vicarious trauma, compassion fatigue, and burnout are all potential hazards of doing empathic clinical work with traumatized clients. Although sometimes used interchangeably, these terms have distinct definitions. Secondary traumatic stress is defined as, “the natural and consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other – the stress resulting from helping or wanting to help a traumatized or suffering person”
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(Bride, Radey, & Figley, 2007, p. 155). Results of this study confirm the work of helping parents can create secondary traumatic stress. From Chapter Eight: I did everything I felt like I could do, but there’s still that doubt. You feel like you need to be superhuman. I should’ve been able to do it all. I should’ve been able to predict it and make it different and make it better. Vicarious trauma has the capacity to alter a person’s inner being. Pearlman and MacIan (1995) define vicarious trauma as, “the transformation that occurs within the therapist (or other trauma worker) as a result of empathic engagement with clients’ trauma experiences and their sequelae” (p. 558). Results confirm that some participants felt their work created transformation in their way of being in the world, as stated in Chapter Eight: Getting rid of the self-doubt and really having self-appreciation, because I know that I am doing the best that I could. But when someone questions that, I question myself. I need to get to that point where I understand that I am doing everything I can, and I don’t need that extra validation. From the same chapter: You get up with the belief that you are helping someone. When you see that it is not turning out the way you envisioned, it gets to be discouraging, to the point where you wonder, “Why am I doing this again?” Then you want to switch to (other clients to) see more tangible results. That is when you have to keep in mind, “Am I doing this for me or am I really doing this for them?” Compassion fatigue is a more “user friendly” term to describe the phenomena of secondary traumatic stress. There are distinctions between vicarious traumatization and
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secondary stress / compassion fatigue. However, “in terms of theoretical origin and symptom foci, all three terms refer to the negative impact of clinical work with traumatized clients” (Bride, Radey & Figley, 2007, p. 156). Regardless of terminology, the 16 research interviews made clear the hazards of empathic connection. Participants talked openly about negative emotions in the clinical sphere. From Chapter Six: It’s like a physical reaction. It just feels gut-wrenching, I know the power of having your kids and the beauty of that. It’s just a basic inherent need. You have children because you want to, so for me it’s really hard, weighing my obligation to what I need to do for the children as well as what I need to do for another mother. It just feels impossible, like I can’t make it. It’s a lot to carry, and I know the burden doesn’t lie with me, but it feels like it does most days. Those things (stay) with me and I take it home. Then sometimes it comes up in my own interactions with my own kids and I feel just sad. Burnout is commonly understood as an accumulation of negative consequences that result in the trauma worker’s disillusionment with work and personal life. Freudenberger (1975) attributes burnout to the demands of work. The actual emotional state is characterized by exhaustion to the point of professional ineffectiveness (Baird & Jenkins, 2003; Maclean, 2011; Maslach & Florian, 1988). Participants understood the hazards of work with this population, and some changed jobs before becoming too exhausted to function.
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Freudenberger postulates that, “We are fighting a battle on at least three fronts. We are contending with the ills of society, with the needs of the individuals who come to us for assistance, and with our own personality needs” (Freudenberger, 1975, p. 73).
The Importance of Empathic Engagement despite the Hazards Parents referred for therapy through the child-welfare system bring with them a multitude of issues. Some of the critical factors impacting how the case will proceed include: 1. Being a mandated client 2. Parent’s history of abuse and neglect 3. Level of trauma experienced by all family members 4. Current court involvement 5. Amenability of the parent to engage in the process of therapeutic connection Being mandated to treatment implies that clients would not be in therapy if not forced. This creates a challenge in developing a therapeutic alliance with mandated clients. Although difficult, the therapist is wise to consider the endeavor as critical in nature. Listening with an empathic ear to the parent’s account of the circumstances that brought them into treatment is a good way to start the development of an alliance (Dinkmeyer, 1999, p. 102). Motivating clients and helping them feel they have some measure of control is a must. A relationship-based practice has risks for both client and social worker. The client brings with them a plethora of complications, including “emotional messiness” (Turney, 2012, p. 157). According to Turney, if clients feel understood, they are less likely to
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abuse and neglect their children. Clinicians must be mindful of their own vulnerabilities and propensities to abuse their power. In addition, engaging mandated clients empathically leaves the therapist more vulnerable to vicarious trauma. Maintaining a well-balanced life, in which work and home are separate, requires the therapist to engage in a self-care strategy (Black & Weinreich, 2001, p. 38). A robust strategy will include supervision with a professional who is well-versed in vicarious trauma and burnout. In this regard, the supportive supervisor needs to provide emotional support. This work will include the identification of personal issues, as well as workrelated stresses and challenges, along with “strategies for addressing them� (Berger & Quiros, 2014, p. 297). A safe supportive supervisor can and must provide the emotional space for self-reflection to occur, allowing for optimal personal and professional growth (Berger & Quiros, 2014).
Managing the Work Participants were generally new therapists when they began working with clients mandated to treatment. Being new to the profession has the potential to make the work more difficult. While learning the profession, therapists must remember an important part of the work is learning to care for self. Canfield (2005, p. 82) cautions therapists to remember the hazards of working with trauma, and to call on others to help manage the emotional cost. Results of this study confirm the importance of seeking help. From Chapter Eight: It really is experience, and kind of developing a thicker skin. Working with people in the domestic-violence programs, you can’t just naturally be good at that.
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You (need) practice of being assertive and hearing all the stories and seeing the patterns. After a while it becomes predictable, so although you are sensitive to it, you don’t get so caught up in it. You begin to understand this dynamic, and it is not so foreign to you. In the same chapter, another therapist was more succinct, saying, “I couldn’t get by without colleagues.” Supervisors and colleagues can provide a safe place for therapists to explore day-today trauma. The support can help reduce feelings of isolation and the shame of having symptoms of vicarious trauma (Harrison & Westwood, 2009, p. 208). Study results confirm the value of quality supervision and peer support. Developing a strategy for self-care can also contribute to the wellbeing of the therapist and ward off the potential for vicarious trauma to turn into burnout. Self-care models applied at the levels of macro (organization), mezzo (clinical teams), and micro (the individual) can help “manage burnout and enhance the possibility of a fuller presence for the client …” (Dombo & Gray, 2013, p. 93). This study confirmed that support at all levels enhanced the work environment and made for an empathic, compassionate clinical space for parents to heal and improve parenting skills. In Chapter Eight, a therapist said, “If it had not been for the colleagues and the support we had from each other, we might not have made it as long as we all did.” Another said, “One of the nice things about being in an agency is that there is still confidentiality, but you have that ability to staff cases in a more direct manner. You are able to vent and process.”
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Supervision is critical for the development of mental-health professionals, especially for those dealing with trauma (Berger & Quiros, 2016). Results confirm that a supportive environment, filled with caring colleagues, played a significant role in the healthy professional development of this group of therapists. Developing and maintaining a rigorous plan for self-care is essential for therapists. Supervisors and peers can provide the needed support for processing cases and managing overwhelming feelings, but they can also serve to remind each other that self-care is an ethical obligation if quality treatment is to be provided for clients. Canfield (2005) believes this is one of the roles supervisors and peers provide. They should “remind therapists of their own realistic limits and insist that they take as good care of themselves as they do of others” (p. 82). Good self-care practices can help to reduce the development of negative consequences that occur with vicarious trauma, secondary traumatic stress, and burnout. “Our direct boss was a very wonderful man,” one participant remembered in Chapter Eight. “He expected a lot from us, and I learned a lot from him. He was very supportive. You would have supervision and you thought you came out of a therapy session.” Elsewhere, research interviews returned this quote: I had both, a very good [supervisor] and then one that was not so much. He was kind of a dictator, who was more about making sure the reports were all dots crossed, and things spelled right. He wasn’t as good as a woman [supervisor] I had, who was actually very compassionate and really made sure that we were taking care of ourselves―”What do you need,” and “What can I do?”
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Results confirm the support of a caring, supportive supervisor can help the therapist to develop good self-care routines that will lead to better treatment for clients. Participants agreed the work can take a toll, yet they returned to it every day. All reported that some form of self-care supported them through difficult times. It is generally agreed that a good self-care plan is essential for therapists engaging in empathic, compassionate connection with clients. (Saakvitne, 2002; Canfield, 2005; Dombo & Gray, 2013; Hernández, Engstrom, & Gangsei, 2010). Results confirmed that self-care routines helped. One therapist said, “I go outside a lot. I do a lot of canoeing and kayaking and stuff like that―not sports-oriented, more like floating casually. And I’ve got friends and a significant other.” In Chapter Eight, a therapist said: I do pray and I try to meditate, but I’m not very good at sitting still. I try to at least take a few minutes to take some deep breaths and make sure that I’m keeping myself calm. Some days you feel like you’re just running back to back to back. Taking a few minutes to meditate (is helpful). Nutrition is a big part of it. If I’m not eating well, I will get angry and that’s never good for anybody. It’s being able to make sure that I am just taking care of even my most basic needs. Creating a safe place, developing health habits, spending time with loved ones, and the availability of quality support at work all contribute to the development of a rigorous self-care plan. Saakvitne (2002) recommends we find a “means for escape.” As the scholar explains, “To balance the cost of bearing witness, we need opportunities that allow us to turn away, to escape from harsh reality into fantasy, imagination, art, music, creativity, and sheer foolishness”
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(p. 448). Participants in this study agreed, reporting that their self-care plans included the removal of negative thoughts from their awareness. “For me it is just mentally getting it out of my head so to speak,” one therapist said. “I find just having ‘me time’ or just spending time with my loved ones helps me to relax.” Another said, “My horse knows when I need a kiss on the cheek and he just lets me go up and hug him and brush him. He is my release.” No one would continue to do clinical work with traumatized clients if there were not some rewards. This study confirmed that the work can fulfil the passions that drive people to pursue such a difficult vocation in the first place. From Chapter Eight: I want people to be aware of how hard it would be when they come into the field. I would not tell them not to do it, if they are passionate for people and helping others and they can stand nasty bugs, stink, sitting with somebody who has a record or is really angry―there might be gunshots outside your door at some point or a drug deal going on around the block―you can make a difference. Having good supervision, peer support, and a healthy self-care plan can help a therapist continue to bear witness to suffering. Hernández, Engstrom, and Gangsei (2010) propose the idea of “vicarious resilience.” By acknowledging the client’s capacity to survive and overcome brutal trauma, the therapist can see the potential in human resiliency (p. 237). Vicarious resilience helps keep therapists coming back to the work every day. As one participant said, “I think that is ultimately what makes it really rewarding, and at the same time challenging. You give of yourself to another person, and you hold them with you, sort of―always, in some cases. That’s OK to me.”
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Participants recognized the capacity people have for growth and change and reported being inspired. It is too bad that the field doesn’t pay better because I think a lot of us would want to do it again. Even with all the pitfalls, there are rewards to it too. Not everything is bad. Sometimes there are happy endings. Kids did go back home and parents had improved, not a lot, but sometimes. When therapists are supported at work and committed to a personal self-care plan, empathic engagement can become a “protective practice” (p. 213). Harrison and Westwood (2009) described “exquisite empathy” as a positive outcome of working with traumatized individuals. The authors cautioned that clinicians must “maintain clarity about interpersonal boundaries” in order to connect on this deep level and experience the positive benefits of client connection (p. 213). Remembering a particular client, one therapist said, “After having a lot of experience with these different cases and different areas, I would kind of say, I do have a lot of empathy for her.” In Chapter Eight, a therapist said: I don’t regret coming to the field. I feel like it’s a good fit for my strengths and my dreams and my passions, all those things. I feel like we make a difference in lives and often I actually feel like we make a difference in lives that we don’t even know, the next generation of the child’s family. Results confirmed that working with parents referred through the child-welfare system can wear on the therapist. For therapists to maintain optimal mental health, they must manage the conflicting emotions that result from empathic, compassionate connection
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with clients. Each therapist should develop a personal plan to ward off negative consequences.
Summary of Implications Therapists working with parents under the watchful eye of the child-welfare system are presented with challenges and rewards. Inevitably this group of therapists are confronted with the horrific stories of abuse and neglect, as perpetrated by their clients. In addition, these parents may themselves be victims of child maltreatment (Child Welfare Information Gateway, 2016), and therefore come with their own stories of abuse and neglect. Bearing witness to the trauma of others can prompt compassion fatigue, secondary traumatic stress, vicarious trauma, and if not addressed, burnout. The therapist must recognize that the work may evoke a variety of emotions. These emotions will create personal reactions that can impede progress in treatment. Also, interference may abound as conflicting “voices� will be present in the clinical encounter, and may cripple the therapist’s capacity for empathic engagement. Participants in this study fully understood these possibilities, and took steps to lessen their potential influence. Therapists recounted stories of tragedy and triumph. In the telling, they explored their own capacity to persevere, even when odds were against successful clinical outcomes. They acknowledged the many feelings evoked by the work, and how they learned to manage those feelings. Some participants wept while retelling stories not only of horrific abuse by the parents they worked with, but also by the systems in charge of those clients.
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The injustices witnessed by the therapists complicated the work, especially as parents often conflated the therapist with “the system.” Interviews explored the dynamic of caring for self while caring for others. Therapists used a variety of creative methods to minimize the harsh truths of child abuse and neglect, including: 1. Swimming 2. Boating 3. Hot baths 4. Reading books 5. Journaling 6. Praying 7. Meditating 8. Exercising 9. Indulging in chocolate 10. Talking to horses Participants understood that their risk of burnout exceeded that of professionals working with other client populations. This knowledge drove them to develop rigorous self-care plans that met their own personal needs. Supervisors and peers provided lifelines to good mental health. Some participants moved into supervisory roles and embraced their responsibility to assist their supervisees by recognizing personal triggers that can occur when doing trauma work. They described their attempts to provide a “respectful forum” for their supervisees, just as Pearlman and Saakvitne (1995) explain in their book, Trauma and the Therapist: Countertransference
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and Vicarious Traumatization in Psychotherapy with Incest Survivors (p.364). Participants considered the emotional space for the examination of countertransference reactions as valuable. They mostly did not use the terminology of psychodynamic theories, but were nonetheless aware of the related concepts, and understood the need for a thorough working-through of transference, countertransference, and enactments. Participants were eager to share their experiences through this study. A few told stories they had never told anyone before. Some cried as they recounted stories of parents losing custody of children. Others recounted the relief of children moving away from abusive parents, into safe homes. Participants expressed appreciation for the study, because they felt their field of work is not sufficiently studied. They hoped that this study could spark interest among other researchers. Therapists explained that many in their personal life don’t want to hear about the horrors of abuse and how it impacts vulnerable people. Additionally, participants recognized the interference that occurs in the clinical encounter with this client population. Lastly, they intimately understood that the work can take an emotional, social, physical, and spiritual toll on the therapist, and therefore a rigorous self-care plan was essential.
Limitations of Qualitative Research Grounded theory, as conceptualized by Kathy Charmaz (2006), invites the researcher to “be a part of the world we study� (p. 10). Meeting with 16 self-referred research participants provided me with the opportunity to gather data and use grounded-theory concepts to wrestle with the information and produce a synthesis of that information. I
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hope this research will be a starting point, and that further research will expand on the concepts gleaned from my interviews with generous, busy clinical professionals. This study is limited. Sixteen self-referred therapists participated in one-hour interviews to talk about their clinical experiences. Given the number of participants and extent of research, the study is not exhaustive. Qualitative research by its very nature is subjective and open to the interpretations of the researcher. Charmaz reminds us that “we are not scientific observers who can dismiss scrutiny of our values by claiming scientific neutrality and authority” (p. 15). Member-checking feedback indicates that the write-up accurately portrayed the experiences of this group of therapists. Participants were given the opportunity to provide feedback or correct errors by responding to an email or by calling the researcher. Seven of the 16 participants responded simply by congratulating me on my ability to capture the essence of what they said. They further thanked me for the opportunity to participate. Although qualitative research does not allow for the unbiased, neutral researcher inquiry that quantitative studies can provide, it does permit a possible starting place or opening for further investigation. I hope this study will inspire the interest of others in the field to pursue further research in the area, so that parents and children will be better served in their clinical encounters with therapists.
Implications for Clinical Practice Clients and therapists work together as “partners who co-construct the treatment process” (Miehls, 2010, p. 370). Empathic, compassionate engagement with clients provides a clinical encounter ripe with possibilities for growth, but also harm. Work with
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traumatized people and people who perpetrate trauma on others requires the therapist to be mindful of both the rewards and hazards.
Empathy. “Empathy requires knowing you know nothing” (Jamison, 2014, p. 5). Empathy demands deep engagement with another, and when employed in social-work practice, outcomes improve (Gerdes & Segal 2011). Clinicians should be mindful that empathy and compassion helps court-mandated parents make progress in treatment. However, this progress requires the therapist to clear the room of the “voices” of the abused children and the system that made the referral. Empathy is vicarious introspection: we understand other people’s feeling states because – to varying degrees – we all share basic human emotions. This is a mode of listening in which the therapist, recognizing the leading affect in the patient’s associations through vicarious introspection, must then make an effort to decentre from her own affects in order to be free to hear what differentiates her own experiences from the patient’s. (Ornstein, 1994, p. 108) When employed in clinical practice, empathy can improve the therapeutic encounter, but therapists must be mindful of where they end and clients begin. For empathic engagement to succeed, the therapist must have boundaries and a keen awareness of self. Supportive supervisors can help if they provide honest feedback in a supportive, compassionate manner.
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Supervision. Supervisory support can be a valuable tool for new and seasoned therapists. Whether or not the organization where the therapist is employed provides supervision, the therapist must seek out a supportive, compassionate supervisory relationship with a seasoned practitioner. This relationship can help the therapist continue to build on selfunderstanding, supply an arena to voice the horror experienced when working with trauma, and build an understanding of transference and countertransference reactions to clients. Hernández, Engstrom, and Gangsei (2010) explain that “vicarious resilience” should be recognized as something positive that can come from working with traumatized people. The resilience of clients in the face of unspeakable horrors can encourage therapists. On the other hand, working in close connection with trauma creates the potential for compassion fatigue, secondary traumatic stress, vicarious trauma, and eventually burnout. The astute clinician will be mindful of the potential for harm, and take steps to create a sturdy self-care plan. The new clinician’s work with a supportive, compassionate supervisor should focus on the deeply personal nature of the work and a healthy understanding of self. Integrating personal identity with their professional role is an important step for the new therapist (Neumann & Gamble, 1995). With proper supervision, a new clinician can development the skill of working in empathic, compassionate engagement with traumatized clients. Using a trauma-informed lens to understand the individual can help with the development of a therapeutic alliance.
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Empathy and compassion help ensure better outcomes, which will also contribute to therapists’ positive feelings about their professional identities.
Implications for Policy Administrators leading organizations that employ new (and seasoned) therapists working with traumatized individuals need to give special attention to a variety of factors. The list includes: 1. Time off and payment for professional conferences 2. Adequate leave time 3. Handling mistakes without retribution 4. Reasonable caseloads 5. Professional space that supports work with trauma survivors 6. Encouragement 7. Financial resources to engage in personal therapy 8. Organizational structure that supports new therapists 9. Supportive supervision to address issues of being new and working with a traumalens Organizational supports increase the chances for continual empathic, compassionate therapy. Harrison and Westwood (2009, p. 213) were “surprised” by findings of their research. Although it is commonly understood that work with traumatized people has the potential for negative impact, the authors learned that it can also be a “protective factor.” Taking the time to develop empathic attunement with clients, if encouraged by
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organizational policy and practice, can help reduce the risk for negative outcomes in employees and clients alike. Working clinically with traumatized individuals comes with its own set of hazards. Supervisors play a key role in helping practitioners integrate knowledge with practice. Their interactions should be supportive and non-shaming. Especially true for new therapists, they must be allowed to fail without retribution. Supervisors play an important role ensuring that the mental-health professionals under their leadership are practicing with a solid trauma-informed base of knowledge (Berger & Quiros, 2016). Reactions generated during trauma-related work can leave the social worker feeling inadequate and unskillful. Results of the study confirm this phenomenon. In Chapter Five, a participant said: She was doing so good just a little bit ago. Now she’s not, so I feel like I failed a little bit. Maybe I didn’t give her enough tools. There is a lot of guilt that comes along with it, but maybe I haven’t lived up to what I should’ve done. In Chapter Seven, a therapist expressed similar self-doubt, asking herself, “Did I really do anything in that hour and a half that I was there? Did I really do anything? That’s kind of how I felt.” When clinicians feel like failures, they need support. Helping therapists understand that their reactions are “normal” should be embedded in organizational culture (Bell, Kulkarni, & Dalton, 2003, p. 466). Supervisors and peers can help individual therapists develop competence in working with this client population. Time allotted for individual and group consultation should be seen as a necessity, not a luxury.
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If organizations wish to reduce the likelihood of vicarious trauma among therapists, they should rigorously evaluate policies and practices at the macro, mezzo, and micro levels (Dombo &, Gray 2013, p. 93). The development of self-care practices should be embedded in the policies of agencies working with traumatized individuals. Also, policies should encourage personal examination of spiritual beliefs that can sometimes be challenged during empathetic engagement with traumatized people. Dombo and Gray argue that leadership should be trained in recognizing signs of vicarious trauma and be prepared to intervene with staff when necessary (2013). Personal coping strategies can help the skilled therapist deal with vicarious trauma. Organizations can help by implementing policies that support their employees (Cohen & Collens, 2012). Results of this study confirm that a supportive environment, where leadership understands the potential for negative consequences, helps ward off the development of vicarious trauma. It has been long understood that working with trauma can create negative consequences for therapists (McCann & Pearlman, 1990; Herman, 1992; Pearlman & Saakvitne, 1995; Pearlman & MacIan, 1995; Radey & Figley, 2007; Bride, 2007; Adam & Riggs, 2008). More recently, attention has been focused on the potential for positive outcomes (Hernández, Engstrom, & Gangsei, 2010; Cohen & Collens, 2013). Sitting with individuals who have endured unspeakable tragedy and hearing stories of survival has the potential to inspire the listener. Trauma survivors can experience both the negative results of their experiences and the positive. Hernández, Engstro, and Gangsei (2010) explore the phenomenon of “posttraumatic growth” (p. 70) and its potential for creating vicarious resilience, a term used to describe the positive impact on therapists when they are
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inspired by the stories of their clients. Organizations would do well to create an institutional culture that encourages staff to focus during meetings and special events on the potential for positive outcomes of the work they do.
Summary Organizations that serve traumatized individuals should institute policies and practices that support their staff. Diligent efforts should be made to create a culture that embraces the whole person: biological, psychological, social, and spiritual. Therapists working closely with trauma survivors risk developing negative personal consequences, and the related organizational cost could also be great, as skills are reduced and high turnover occurs. Organizations, staff, and clients all benefit when rigorous efforts are made to create a safe, supportive, and inclusive working environment.
Future Research The experiences of this small group of therapists provide a beginning level of insight into the impact the work has on the therapist’s personal and professional life, and the lives of their clients. Further research is needed to expand on the multiple aspects of the work revealed in this study. Expanding on the knowledge that the work is considered “hard� could help people in the field develop policy and practice to reduce potential negative consequences. A more thorough understanding of transference, countertransference, and the potential for developing vicarious trauma could help reduce interference experienced in the clinical
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encounter. Examining the ways these types of therapists manage the negative consequences of their work is another area for study. Researchers should also examine how public policy can address the horror of child abuse and neglect in America and to reduce the isolation felt by victims and their helpers. Many refuse to acknowledge the prevalence rates of abuse, and further research should address this issue. This study is only a small beginning that opened a glimpse into the lives of therapists working with parents referred through the child-welfare system. Much more research is needed to have a better understanding of their experiences. Additional research would benefit the therapeutic community and the clients they serve.
Final Thoughts In the fall of 2016, the university where I am employed granted me a four-month sabbatical for the purpose of completing my research. My time is split between teaching and doing administrative work with the latter being the majority. As the social-work Department Chair and BSW Director at a small evangelical Christian university, I stand between two often conflicting sets of values that find me at odds with my colleagues no matter where I go. While attending social-work conferences I have had people ask me, “How can you be a social worker and teach at that school?� When I have been in university meetings, I have been looked upon with shame when I advocate for our LGBT students and their right to study at our institution while fully embracing who they are. This sometimes leaves me feeling very lonely. In the fall of 2015, I taught an Introduction to Social Work course for 23 young, eager, new social-work majors. The political climate was heating up and social media was
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awash with stories, sometimes true and sometimes not so true. To help our new socialwork majors make informed decisions regarding their world (and in particular the upcoming election), I created an assignment that required them to compare what was being said on social media regarding a particular area of interest to social workers, to what was being said in the reliable news. Presentations were made during class time and students were finding the differences. The assignment was a success, so I repeated it again in the Spring 2016 semester. I worked through the summer months satisfied that I had left my young students with information on how to be informed citizens. Then I left on sabbatical at the end of August 2016. I spent the fall traversing the countryside interviewing and returning home to transcribe. I would get another lead for a research participant and I would go out and interview, return home, and transcribe. I employed the rigor of grounded-theory research to the best of my ability, mindful that I held some bias for the subject because of my own experiences with the client population. The interviews garnered rich data that resonated with my own experiences in the field, and I felt a sort of kinship with my research participants. Some of the interviews were emotional and some left me joining them in their frustrations. With each fresh interview, I believe I improved my ability to use curiosity and dig deeper into participants’ experiences. I would go home at night and watch the news on television and read the newspaper and various magazines. Before the end of the day, I usually jumped on social media to see what was being spread and what my “friends� were saying on Facebook. As November 8th drew near, I watched in horror as Donald Trump appeared to be gaining in popularity. Like many others, I was in denial that he could possibly win,
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especially after the video that showed him talking to a reporter about the things he could do to women because of his celebrity status. I continued with my coding and research and tried to stay focused on my writing. At some point about halfway through my coding I was stuck. I could not think about my participants, what they told me, what it meant, how to write about it, what trauma does to an individual, child abuse, government agencies―and what all this was doing to me and others working with families caught up in the child-welfare system. Then, before I would go to sleep for the night, I would check Facebook. Two of my “friends” on Facebook held diametrically opposing views on the election and were quite vocal. Both engaged in name-calling, spread untruths, and promised to block anyone who did not agree with their opinions. Their comments were occasionally so vile that they were hard to read. I found myself feeling confused, frustrated, and sad all at the same time. The pro-Trump “friend” mostly talked about gun control, “dishonest Hillary,” emails, and the economy. The anti-Trump “friend” pleaded with listeners to see Trump for who he truly was and vote for Hillary. She reminded everyone reading her posts about the horrible things Trump said about women, immigrants, people of color, the disabled, and so on. I remained perplexed. Both Facebook friends are incest survivors. The anti-Trump “friend” reminded her readers she had been abused by a “pervert” and pleaded with her friends, saying, “Please don’t put a pervert in the White House.” The pro-Trump “friend” continued to sing the accolades of this “wonderful man” who was going to save America and make it great again. I know the devastation the abusive fathers caused in their lives. I read the posts to my husband. I processed with my consultation group. I talked to
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therapist-friends. The pro-Trump supporter confused me the most. Certainly she knows the reality of child sexual abuse because she experienced it. Certainly she understands that people talking like Donald Trump did with Billy Bush in the video that aired on October 7th, 2016 contribute to the continuation of rape culture. She of all people should know this. She experienced it. Were we really going to put someone in the White House who promotes rape culture by participating in demeaning conversations about women? Then it struck me: The power of denial cannot be ignored. We really do live in a country of people who disavow the brutal reality and magnitude of the problems of poverty, childhood abuse and neglect, rape, domestic violence, racism, ageism, misogyny, and every other -ism that degrades and dehumanizes groups of individuals. Listening to the news and reading those posts on Facebook helped me recognize my own inclination to deny the reality of abuse and neglect. Like my pro-Trump “friend,� I was defending against that which is too horrible to imagine. I could not face the horror of what I was hearing from my research participants, including dead babies, fathers molesting their daughters, termination of parental rights, and even feelings of guilt from knowing you have done some of the same things that your client is now under threat of losing her children for. Little is written about the experiences of therapists doing this work. It has been difficult to find information to validate my own experiences, but the research participants told me what I knew to be true: The work is very hard and it can take a toll on the therapist if not managed well with good self-care. I wanted to deny it. There is this fabric to American life that people don’t want to know about. Sometimes, even those of us who
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do know about it don’t want to. We all filter what we don’t want to hear. We defend against the terror of what humans do to one another. We live in a culture of disavowal. It has taken me too long to complete this Ph.D. Life got in the way and work got in the way. My friends and family want me to do things and I cannot because I am trying to complete this program. I feel guilty when I am not writing or studying. I want to be done. But one of the things I learned is I am not done. Although I knew about the experiences of therapists working with parents who lost custody of their children or were under threat of loss, I did not understand it in the same way I do now. The impact can be far-reaching. Defending against that which we cannot hear because it is too hideous can even impact a presidential election. Our inclination may be to use our defenses to ward off the hideous truth of what happens in our homes and communities, but this group of therapists must face it every day and learn how to cope. They may use denial for a minute to get them through a rough day. Although the work is hard and can cause some to experience vicarious trauma, people continue to do the work because they believe they are making a difference for some families. The occasional feelings of vicarious resilience can help sustain them, just like it does me.
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Appendix A Phone Script
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Phone Script
Thank you for responding to my email / flyer. My name is Bonnie Holiday and I have been doing clinical social work for over 20 years. I am completing my dissertation for my Ph.D. in clinical social work through the Institute for Clinical Social Work in Chicago, Illinois. I am conducting a qualitative research study of clinical social workers and their experiences working with parents who have lost or are threatened with loss of custody of their children. Very little is written about clinical work with this population of clients. Through the completion of this study I am hoping to add to the body of knowledge regarding this clinical work. I am requesting we meet for one hour at a location of your choosing. Our meeting will be audio-recorded for later transcription. The contents of the interview will be kept confidential. I am the primary transcriber. However, I do have a team of colleagues that may assist with the transcribing. They have all signed confidentiality agreements. A follow-up second interview may be required for clarification purposes and may be conducted on the phone or in person. A draft of the results of the study will be sent to you and you will be given to opportunity to comment via email or phone. There are no personal benefits. However, you will be helping to contribute to the body of knowledge regarding this clinical work. You will be given a $10.00 gift card for participating.
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Do you have any questions for me? I will need your written permission to participate in the study. I have a detailed consent form that I would like to send you to review before we meet. May I have your email address so I can send it to you?
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Appendix B Participant Consent Form
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Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research Exploring facets of involuntary separation between parents and children: A clinical social work perspective.
I, ____________________________________, acting for myself, agree to participate in the research study entitled: Exploring facets of involuntary separation between parents and children: A clinical social work perspective. This work will be carried out by Bonnie Holiday under the supervision of James Lampe, PhD., the Dissertation Chair. This study is conducted under the auspices of the Institute for Clinical Social Work, 401 S. State Street, Suite 822, Chicago, IL 60605, (312) 935-4232, as part of the requirements for fulfilling the Ph.D. program. Purpose The purpose of this study is to build knowledge regarding the intrapsychic experience of therapists working with parents who have lost or are threatened with loss of custody of their children involuntarily and identify factors that may enhance or impede the clinical work with this client population. Procedures Used in the Study and the Duration Participation in this study will involve being interviewed. The interview will last 1 hour in length. The time frame for completing the interview will depend on both the availability of the participant, and the ability to coordinate scheduled times with the
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researcher. If you agree to participate in this study, you must be willing to do the following: sign a consent form, schedule and participate in a one-hour interview at a minimum and location convenient for both you and researcher, complete a demographic interview form at the beginning of the interview and agree that each interview will be audio-tape recorded. Participants will be asked for a second interview if they believe they have more to add to the initial interview or for purposes of clarification. The second interview may be conducted by phone. Participants are free to decline the second interview if they feel they have nothing to add. A $10.00 gift card will be given to each participant. After the interview(s) participants will have the opportunity to review the researcher’s analysis of their verbal feedback. A draft of the results will be sent to participants and they will be offered the opportunity to comment via email or by phone. Benefits There are no known benefits to participating in the study however a feeling of personal satisfaction may be realized by participants as they share their experience of working with clients mandated to treatment through the child welfare system. Costs There will be no monetary costs to the participants involved in this study. Possible Risks and / or Side Effects The researcher does not expect the interview questions to cause you any distress. However, you may find discussing your thoughts and experiences on your work to be distressing. If this happens, you may skip any questions that you do not want to answer, take a break, or end the interview.
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Another concern may be loss of confidentiality. The information you share will only be used by the researcher. No one else will have access to the data. You will be assigned an identification number and your name will be removed from the survey. The list connecting your name with the identification number will be stored separately from the survey data. It will be destroyed once we have completed data collection. Privacy and Confidentiality Participant will be assigned a pin number. The key to the pin numbers will be kept in a locked confidential file cabinet similar to that kept for client records. The audio recordings will be transcribed on a password protected laptop computer. The paper copies of the interviews along with the audio recordings will be kept in a locked file cabinet. When in transport to consultation with faculty they will be in a locked case. Five years after the completion of the study all interview materials will be destroyed. The computer files will be destroyed using “file shredding� software. Cassette tapes and/or USB thumb drive recordings of interviews and paper transcriptions will be destroyed by fire. Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness. I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of ICSW will not be affected in any way, now or in the future, if I refuse to take part or if I begin the study and then withdraw.
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If I have any questions about the research methods, I can contact Bonnie Holiday, Principal Researcher (517-206-3869), or James Lampe, Dissertation Chair (773-6651380). If I have any questions about my rights as a research subject, I may contact Dr. John Ridings, Chair of Institutional Review Board; ICSW; at Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605; (312) 935-4232. Signatures I have read this consent form and I agree to take part in this study as it is explained in this consent form. ________________________________________________ __________________ Signature of Participant
Date
I certify that I have explained the research to _________________________________________ and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward.
________________________________________________ __________________ Signature of Researcher
Date
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Appendix C
Semi-Structured Interview Questions
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Semi-Structured Interview Questions This is a dialogue so you can ask questions as we go along. I am interested in what this type of work evokes in you. You are the expert here today. What I am looking for is information about YOUR experience working with parents who lost custody or were under threat of losing custody of their children. I understand from our conversation on the phone that you have ________ years of experience with these kinds of cases and that you saw these cases as part of your work at __________ agency (private practice). • How did you get into this work (in general and specifically with this population of clients)? o PROMPTS: motivations, influences, personal experiences • Can you describe your range of experience when working with these families, the good, bad and ugly? • What is it like developing a trusting relationship with someone you are required to send progress reports about to the caseworker / court? o PROMPTS: manageable, difficult, similar to other situations • When sitting with a parent what does it evoke in you? o PROMPTS: strong feelings, fight / flight, question your own parenting • After children have been removed and you are involved when reunification, occurs how does it feel for you? o PROMPTS: stressful, rewarding, exciting, scary, frustrating • How do you feel when parental rights are terminated? o PROMPTS: I found myself feeling responsible and I was often felt sad, like a failure, or that justice was done • What is helpful to you when working with these parents? o PROMPTS: in the work, in your professional life, in your personal life • What are your thoughts about these cases when you are not at work? o PROMPTS: What allows you to come back to it? • What prepared you to work with this client population? o PROMPTS: School, personal experience, mentor, supervisor, colleagues o What did that (the preparation) mean for you? • What keeps you doing these cases? o PROMPTS: Are you hopeful? Is it meaningful? How do you handle the difficult situations? • Are there other things you do in addition to these cases? What are they? o PROMPTS: How does that compare to these cases? When you compare how does it make you feel? • What do you say to people when they ask about your work? o PROMPTS: Do you describe the challenges or rewards?
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References
Adams, S.A. & Riggs, S.A. (2008). An exploratory study of vicarious trauma among therapist trainees. Training and Education in Professional Psychology 2(1), 2634. Administration for Children and Families, (2013). Retrieved on March 28, 2015 from http://www.acf.hhs.gov/ Adoption and Safe Families Act (1997). Retrieved on March 28, 2015 from https://www.childwelfare.gov/ Alpert, L. (2005). Research review: Parents’ service experience – a missing element in research on foster care case outcomes. Child and Family Social Work, 10, 361366. Altman, N. (1995). The analyst in the inner city. Boca Raton, FL: The Analytic Press. Aron, L. & Harris, A. (2005). Relational psychoanalysis: innovation and expansion. Hillsdale, NJ: The Analytic Press, Inc. Adshead, G., Paz, I., King, C., & Tagg, A. (2010). Attachment and risk: A therapeutic risk assessment group for parents who have hurt their children. Attachment: New Directions in Psychotherapy and Relational Psychoanalysis. 4(3), 203-215. Baird, S. & Jenkins, S.R. (2003). Vicarious traumatization, secondary traumatic stress, and burnout in sexual assault and domestic violence agency staff. Violence and Victims, 18(1), 71-86.
186
Baistow, K. & Hetherington, R. (1998). Parents’ experiences of child welfare interventions: An Anglo-French comparison. Children & Society. 12, 113-124. Balint, A. & Balint, M. (1939). On transference and counter-transference. International Journal of Psycho-Analysis, 20, 223-230. Bell, H., Kulkarni, S. & Dalton, L. (2003). Organizational prevention of vicarious trauma. Families in Society. 84(4), 463-470. Berger, R. & Quiros, L. (2016). Best practices for training trauma-informed practitioners: Supervisors’ voice. Traumatology 22(2), 145-154. Black, S. & Weinreich, P. (2001). An exploration of counsellors who deal with trauma. Traumatology, 6(1), 25-40. Borden, W. (2000). The relational paradigm in contemporary psychoanalysis: Toward a psychodynamically informed social work perspective. Social Service Review (September) 352-379. Bowen E. L., (2010). Court-mandated group treatment for a violent woman: Roxy. Partner Abuse 1(1) 105-116. Doi: 10.1891/1946-6560.1.1.105 Bride, B. E. (2007). Prevalence of secondary traumatic stress among social workers. Social Work. 52(1), 63-70. Bride, B.E., Radey, M., & Figley, C.R. (2007). Measuring compassion fatigue. Clinical Social Work Journal. 35, 155-163. DOI 10.1007/s10615-007-0091-7 Burke, A. C. & Gregoire, T. K. (2007). Substance abuse treatment outcomes for coerced and noncoerced clients. Health and Social Work 32(1) 7-15. Retrieved from http://infotrac-college.thomasonlearning.com/itw/informark/
187
Canfield, J. (2005). Secondary traumatization, burnout, and vicarious traumatization: A review of the literature as it relates to therapists who treat trauma. Smith College Studies in Social Work. 75(2), 81-101. CDC.gov - Child maltreatment facts website https://www.cdc.gov/violenceprevention/childmaltreatment/ retrieved 1-13-2017 CDC.gov – child abuse definition https://www.cdc.gov/violenceprevention/childmaltreatment/definitions.html Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. London: Sage Publications. Child Welfare Information Gateway. (2012). Foster care statistics 2011. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved on December 26, 2013, from https://www.childwelfare.gov/pubs/factsheets/foster.pdf Child Welfare Information Gateway – Enhancing Permanency for Youth in Out-of-Home Placement https://www.childwelfare.gov/pubPDFs/enhancing.pdf Child Welfare Information Gateway – Intergenerational Patterns of Child Maltreatment: What the Evidence Shows. August 2016. https://www.childwelfare.gov/pubPDFs/intergenerational.pdf Cohen, K. & Collens, P. (2013). The impact of trauma work on trauma workers: A metasynthesis on vicarious trauma and vicarious posttraumatic growth. Psychological Trauma: Theory, Research, Practice and Policy. 5(6), 570-580. Creswell, J.W. (1998). Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage Publications.
188
DeJong, P. & Berg, I. (2001). Co-constructing cooperation with mandated clients. Social Work, 46(4), 361-374. Dinkmeyer Jr., D. (1999). Working with court-ordered and mandated parents. The Journal of Individual Psychology. 55(1), 100-104. Dombo, E.A. & Gray, C. (2013). Engaging spirituality in addressing vicarious trauma in clinical social workers: A self-care model. Social Work and Christianity, 40(1), 89-104. Eiseley, L. (2016). The Unexpected Universe New York, NY: Literary Classics of the United States, Inc. Flemons, D., Liscio, M. & Rebholz, C. L. (2010). Fostering solutions: Bringing brieftherapy principles and practices to the child welfare system. Journal of Marital and Family Therapy 36(1), 80-95. Doi: 10.1111/j.1752-0606.2009.00181.x Fosha, D., Siegel, D.J., & Solomon, M.F. (2009). The healing power of emotions: Affective neuroscience, development and clinical practice. New York, NY: W.W. Norton & Company, Inc. Freud, S. (1910). The future prospects of psychoanalytic therapy. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XI (1910): Five Lectures on Psycho-Analysis, Leonardo da Vinci and Other Works, 139-152. Freud, S. (1915). Observations on transference-love (Further Recommendations on the Technique of Psycho-Analysis III). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, 157-171. Retrieved from http://icsw.edu/password/poxyb3/ index.php
189
Freudenberger, H.J. (1975). The staff burn-out syndrome in alternative institutions. Psychotherapy: Theory, Research and Practice. 12(1), 73-82. Ganzer, C. (2007). The use of self from a relational perspective. Clinical Social Work Journal, 35(2), p. 117-123. http://dx.doi.org/10.1007/s10615-007-0078-4 Gerdes, K.E. & Segal, E. (2011). Importance of empathy for social work practice: Integrating new science. Social Work, 56(2), 141-148. Ghent, E. (1989). Credo – the dialectics of one-person and two-person psychologies. Contemporary Psychoanalysis, 25, 165-211. Greenberg, J.R. & Mitchell, S.A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Harrison, R.L. & Westwood, M.J. (2009). Preventing vicarious traumatization of mental health therapists: Identifying protective practices. Psychotherapy Theory, Research, Practice, Training, 46(2), 203-219. Haskett, M.E., Scott, S.S., & Ward, C.S. (2004). Subgroups of physically abusive parents based on cluster analysis of parenting behavior and affect. American Journal of Orthopsychiatry, 74(4), 436-447. DOI: 10.1037/0002-9432.74.4.436 Heimann, P. (1950). On counter-transference. International Journal of Psycho-Analysis, 31, 81-84. Herman, J.L. (1992). Trauma and Recovery. New York, NY: Harper Collins Publishers Hernåndez, P., Engstrom, D. & Gangsei, D. (2010). Exploring the impact of trauma on therapists: Vicarious resilience and related concepts in training. Journal of Systemic Therapies. 29(1), 67-83.
190
Honea-Boles, P. & Griffin, J.E. (2001). The court mandated client: Does limiting confidentiality preclude a therapeutic encounter? TCA Journal. 29(2), 149-160. Hoffman, I.Z. (1983). The patient as interpreter of the analyst’s experience. Contemporary Psychoanalysis 19, 389-422. Honea-Boles, P. & Griffin, J. E. (2001). The court-mandated client: Does limiting confidentiality preclude a therapeutic encounter?, Texas Counseling Association Journal. 29(2), 149-160. Retrieved from http://ezproxy.arbor.edu:80/login?url=http://search.proquest.com Jacobs, T.J. (1999). Countertransference past and present: A review of the concept, International Journal of Psycho-Analysis, 80(3), 575-595. Jamison, L. (2014). The Empathy Exams. Minneapolis, MN: Graywolf Press. Janoff-Bulman, R. (1989). Assumptive worlds and the stress of traumatic events: Applications of the schema construct. Social Cognition. 7(2), 113-136. Kemp, S. P., Marcenko, M. O., Hoagwood, K., & Veneski, W. (2009). Engaging parents in child welfare services: Bridging family needs and child welfare mandates, Child Welfare 88(1), 101-126. Doi: 0009-4021/2009/0109101-126 Lehmer, M. (1986). Court ordered therapy: Making it work. The American Journal of Forensic Psychology 4(2), 16-24. Little, M. (1951). Counter-transference and the patient’s response to it. International Journal of Psycho-Analysis, 32, 32-40. Linley, A.P. & Stephen, J. (2007). Therapy work and the therapists’ positive and negative well-being. Journal of Social and Clinical Psychology. 26(3), 385-403.
191
Lipsky, L.v.D. & Burk, C. (2009). Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others. San Francisco, CA: Berrett-Koehler Publishers, Inc. Macchi, C.R., Johnson, M.D. & Durtschi, J.A. (2014). Predictors and processes associated with home-based family therapists’ professional quality of life. Journal of Marital and Family Therapy. 40(3), 380-390. Maclean, S. (2011). The Social Work Guide to Stress and Burnout. Great Britain: Nexus Total Print Solutions Ltd. Manchak, S.M., Skeem, J.L. & Rook, K.S. (2014). Care, control, or both? Characterizing major dimensions of the mandated treatment relationship. Law and Human Behavior, 38(1), 47-57. DOI: 10.1037/lhb0000039 Maslach, C. & Florian, V. (1988). Burnout, job setting, and self-evaluation among rehabilitation counselors. Rehabilitation Psychology. 33(2), 85-93. Miehls, D. (2010). Contemporary trends in supervision theory: A shift from the parallel process to relational and trauma theory. Clinical Social Work Journal, 38, 370378. Miller, L. (1998). Our own medicine: Traumatized psychotherapists and the stresses of doing therapy. Psychotherapy. 35(2), 137-146. Miller, M. (2003). Working in the midst of unfolding trauma and traumatic loss: Training as a collective process of support. Psychoanalytic Social Work 10(1), 725. Mitchell, S. A. (1988). Relational Concepts in Psychoanalysis: An integration. Cambridge, MA: Harvard University Press.
192
Mitchell, S., & Aron, L. (1999). Relational Psychoanalysis: The Emergence of a Tradition. Hillsdale, NJ: The Analytic Press. Neumann, D.A. & Gamble, S.J. (1995). Issues in the professional development of psychotherapists: Countertransference and vicarious traumatization in the new trauma therapist. Psychotherapy 32(2), 341-347. Ogden, T. H. (1995). Analyzing forms of aliveness and deadness of the transferencecountertransference. International Journal of Psycho-Analysis, 76, 695-709. O’Hare, T. (1996). Court-ordered versus voluntary clients: Problem differences and readiness for change. Social Work, 41(4), 417-422. Ornstein, A. (1994). Empathy, and the interpretive process, and the relativity of psychoanalytic cure. Canadian Journal of Psychoanalysis, 2(1), 103-117. Ornstein, E. & Ganzer, C. (2005). Relational social work: A model for the future. Families in Society, 8(4), 565-572. Pearlman, L.A. & MacIan, P.S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research and Practice. 26(6), 558-565. Pearlman, L.A. & Saakvitne, K.W. ( 1995). Trauma and the Therapist: Countertransference and Traumatization in Psychotherapy with Incest Survivors. New York, NY: W.W. Norton & Company, Inc. Phillips, D. (2009). Clinical social work and psychoanalysis: Introduction to the special issue. Clinical Social Work Journal 37, 1-6. DOI: 10.1007/s10615-008-0177-x Radey, M. & Figley, C.R., (2007). The social psychology of compassion. Clinical Social Work Journal 35, 207-214. DOI 10.1007/s10615-007-0087-3
193
Racker, H. (1968). Transference and Counter-Transference. New York: International Universities Press, Inc. Regehr, C. & Antle, B. (1997). Coercive Influences: Informed consent in courtmandated social work practice. Social Work 42(3), 300-306. Retrieved from http://ezproxy.arbor.edu:80/login?url=http://search.proquest.com Ringstrom, P.A. (2010). Meeting Mitchell’s challenge: A comparison of relational psychoanalysis and intersubjective systems theory. Psychoanalytic Dialogues 20, 1996-218. Rogers, C. (1975). Empathic: An unappreciated way of being. The Counseling Psychologist. 5(2), 2-10. Saakvitne, K.W. (2002). Shared trauma: The therapist’s increased vulnerability. Psychoanalytic Dialogues, 12(3), 443-449. Schwandt, Thomas A. (2000). Three epistemological stances for qualitative inquiry: Interpretivism, hermeneutics, and social constructionism. The Handbook of Qualitative Research. Newberry Park, CA: Sage Shearer, R. A. (2000). Coerced substance abuse counseling revisited. Journal of Offender Rehabilitation, 30(3/4), 153-171. Shearer, R. A. (2003). Court ordered counselling: An ethical minefield for psychotherapists. Annals of the American Psychotherapy Association, 6(3), 8-11. Skeem, J. L., Eno Louden, J., Polaschek, D. & Camp, J. (2007). Assessing relationship quality in mandated community treatment: Blending care with control. Psychological Assessment 19(4), 397-410. DOI: 10.1037/1040-3590.19.4.397
194
Snyder, C. M. J. & Anderson, S. A. (2009). An examination of mandated versus voluntary referral as a determinant of clinical outcome. Journal of Marital and Family Therapy. 35(3). doi: 10.1111/j.1752-0606.2009.00118.x Stern, A. (1924). On the counter-transference in psychoanalysis, Psychoanalytic Review, 11, 166-174. Retrieved from http://icsw.edu/password/poxyb3/index.php Stolorow, R. D. & Atwood, G.E. (1992). Contexts of Being: The Intersubjective Foundations of Psychological Life. Hinsdale, NJ: The Analytic Press. Swift, J. K. & Derthick, A. O. (2013). Increasing hope by addressing clients’ outcome expectations. Psychotherapy 50(3), 284-287. Teitelbaum, S. (1991). Countertransference and its potential for abuse. Clinical Social Work Journal. 19(3), 267-277. Thornberry, T.P. & Henry, K.L. (2013). Intergenerational continuity in child maltreatment. Journal of Abnormal Child Psychology 41, 555-569. Turney, D. (2012). A relationship-based approach to engaging involuntary clients: The contribution of recognition theory. Child and Family Social Work 17, 149-159. DOI: 10:1111/j.1365-2206.2012.00830.x U.S. Department of Health and Human Services Administration for Children and Families, Administration on Children Youth and Families, & Children’s Bureau, (2012). Child maltreatment 2012. Retrieved December 26, 2013, from http://www.acf.hhs.gov/sites/default/files/cb/cm2012.pdf
195
U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children Youth and Families – Office of Data, Analysis, Research, and Evaluation. (2013). Data Brief 2013-1 – retrieved 12-2713. van Heugten, K. (2011). The meaningfulness of helping others: Loren Eiseley’s “The Star Thrower”. Psychoanalytic Social Work 18(2), 126-135. Waldman, F. (1999). Violence or discipline: Working with multicultural court-ordered clients. Journal of Marital and Family Therapy. 25(4), 503-515. Will, O.A., Jr. (1968). The reluctant patient, the unwanted psychotherapist-and coercion. Contemporary Psychoanalysis, 5, 1-31. Winnicott, D. W. (1949). Hate in the counter-transference. International Journal of Psycho-Analysis, 30, 69-74.