My alma mater, Seattle University, offers a brilliant course for masters-level therapists-in-training in the Existential Phenomenological Psychology program. It’s called “The World of the Clinic”, and students take this course at the same time that they begin their practical internships. The course encourages students to think broadly and critically about the social and political forces that shape the work of therapy. So, for example, just as you are learning to actually diagnose someone for the very first time with a potential mental “disorder”, you are learning about the disturbing and sometimes violent history of psychiatric treatment, and you are challenged to place yourself within that history as an active agent. Just as you are learning to work with someone suffering because of their mental health, you are simultaneously being introduced to the inner workings of a medical establishment that sometimes contributes to that suffering by pathologizing marginalized experiences, such as homelessness, poverty, neuroatypicality, or gender diversity. Just as you are struggling to integrate this whole new field of knowledge into an hour with someone who might simply need someone to listen to them and validate them, you are also tasked with questioning the very assumption that this kind of work “knows” anything at all. It’s an amazing course. One of our assignments, conceived by the equally brilliant Dr. Erica Lilleleht, was to write a letter to a student who will come into the program the following year, for them to read as they begin their own practical internship. I had the great honor of speaking with the student who read my letter, and the conversation that ensued inspired me to share what I had written. So here it is, in slightly edited form. Enjoy.
I imagine that my fellow second-year students are beginning their letters in much the same way: these are unprecedented times, and it’s impossible to know what the next year will bring. It is impossible to know what situation you will be stepping into when you begin your clinical internship sometime between July and September of 2021. My class is currently experiencing the heartbreak of not getting to be with one another as we navigate these untested and uncharted waters. We had only talked briefly of telehealth in our classes sometime before the shutdown last spring, and now we are almost exclusively working over the phone or online in ways that are challenging some of the fundamental assumptions we might have brought to our ideas about the practice of therapy, and what it means to be with one another and to be present to one another. Your class is getting to know each other via distance learning, and when you do get to meet in person it will be in an unforeseen situation. I hope it will at least be somewhat familiar. You’ve jumped head-first into a new career on the wave of a global health crisis the likes of which the world has never seen before. You’ve been given an opportunity to be on the front lines of innovation and change in mental health services, but things will likely never be the same again. It’s just impossible to know. For me, there is excitement and grief, loss and hope, in all of this.
However, there are some things that you can be sure of. The first is your firm foundation in the existential-phenomenological (EP) tradition. No matter who you are working with or how, your EP foundations will orient you and steady you. For me, that has meant focusing on the existential questions of making meaning at the crossroads of existence: what does it mean to be free, to choose, to be responsible, and aware? And phenomenologically, I try to feel into the experience of space, time, the embodied, and the relational. As with Gadamer’s “fusion of horizons,” the event of understanding between patient and therapist is the co-creation of new knowledge that looks beyond the individual and has an integrity and life of its own. When I let go of my own understanding (the temptation to “totalize” the situation or the person, as Levinas might say), that is when real insight comes. I guess my first piece of advice is to remember that therapy is not psychology. It draws from that science, but it is an art. Decades of research has shown that the modality of therapy is not as important as the establishment of the therapeutic relationship. It is the event of the coming together of two or more people in the attempt to know and understand across the distances of difference that has a therapeutic effect. We can chart the data of how this happens: we can measure behaviors and to some degree moods that change as a result of therapy, but we can’t say why exactly healing takes place. We only know that it does. Therapeutic practice necessitates a kind of faith, and without that faith, I think it’s an empty thing.
I believe that when therapy is done well, it will always have a spiritual dimension, and if that spiritual dimension is honestly acknowledged, we will see that it motivates and upholds the work of justice. My second piece of “advice” is not to downplay the importance of what you are doing. The ramifications of holding someone in unconditional positive regard are enormous. I have started to see the small effects of this three months into my internship, and as small as those things are, they are breathtaking. Everyone deserves mental health care, just as we deserve universally available care for the rest of our bodies. If you continue to work in community mental health, you will have the opportunity to get to know, if you don’t already, the medical system from the inside out. And we can work from the inside out to bring us step by step closer to a more just society. To quote Angel Kyodo Williams, an esteemed Zen priest and the second Black woman recognized as a teacher in the Japanese Zen lineage, from a 2018 interview:
“To do our work, to come into deep knowing of who we are — that’s the stuff that bringing down systems of oppression is made of. And so capitalism in its current form couldn’t survive. Patriarchy couldn’t survive. White supremacy couldn’t survive if enough of us set about the work of reclaiming the human spirit, which includes reclaiming the sense of humanity of the people that are the current vehicles for those very forms of oppression.”
Not only will you be starting your internship on the wave of this pandemic in whatever form that will take (again, impossible to know!), you’ll be seeing patients whose health care will be impacted or will have been impacted in some way (impossible to know!) by the political changes and challenges we’ve witnessed over the past several years. Working as I do out in a rural area, I have people on my caseload with whom I do not see eye to eye politically. I have encountered situations where I have had to honestly speak my discomfort with an idea or an attitude, because I felt that to ignore it would have given a false impression of myself, but more importantly, I knew that to fail to address a racist comment would itself perpetuate racism, and I knew that to allow a sexist joke was to allow a kind of violence to continue. I know that some people would vehemently disagree with addressing such concerns in therapy. Truly, you must carefully consider when and how to do so. All I can say is that when I have spoken my true discomfort honestly, directly, and nonjudgmentally, it has opened up intense conversations that I believe have productively deepened the relationships.
Now on to some nuts and bolts. My third piece of advice is to remember to slow down. It’s so easy to get swept up into a situation and forget that you don’t have to do anything or decide anything now (or at least, that’s very rare. A crisis situation might mean you need to act immediately, but you should not be working with crisis clients at this point). I learned this lesson the hard way recently: I made a decision based on advice from my supervisor that ended with my client dropping me. What I didn’t remember was that the urgency I was feeling wasn’t necessarily so. I could have stopped and asked for advice from another clinician or a professor. Consult consult consult. It will never do you wrong. Take more time than is necessary, even now.
You are there to learn, and this is YOUR education. Take advantage of as many trainings as you can—they count toward your internship hours! If you want to do a group, create a group and do it! If you want to shadow a person or a process and it’s not already part of your training, just ask! That being said, it’s also easy to work a lot harder than you have to. Watch your hours, make sure you take your vacation time that is due to you, and beware the difference between an educational opportunity and being used as free labor. You’ll know the difference.
Whatever site you’re at, there will be many moving parts. The purpose of “World of the Clinic”, as I see it, is to get you to take a step back and get to know the site as a dynamic process within which you play a small but important role. The more you get to know the details of this process (for example, who empties your trash at night? Do you know? Do you know who schedules your clients? Do you know who updates the clinic’s software?), the more you’ll understand your place within it, just as we are learning the place of mental health work within the larger social, cultural, and political systems that shape our lives. Last of all, don’t worry. You’re here because you’re already doing what it is you’re becoming a professional to do. You’re here because you’ve been called, and you are needed.