Before I became a therapist I had brief stints at some different community mental health agencies. These were experiences that I sought out in order to get into grad school. I worked for about 6 weeks at a housing facility that also served as a women's shelter at night. Sometime like 30 units and 25 beds in the shelter.
I was making minimum wage and left partly for financial reasons, but also partly because I was under-prepared for the intensity of what I encountered. I had never worked in mental health. I had never encountered individuals that had experienced intense trauma and long periods without housing. It was jarring. It was an experience of long stretches of quiet and boredom punctuated by intense moments of conflict and often threats of violence. My therapist at the time likened it to being like a firefighter, sitting around with nothing to do, until suddenly there is something urgent to do. From boredom to adrenaline and back, just like that.
One of the things that was so surprising to me was that my role had both very low and very high expectations. As a 'residential counselor' my main task was to be a presence. I had clients with particular needs that I interacted with regularly (dispensing medication, chatting, computer time), and there were clients who lived there that I barely ever encountered. I was mostly just hanging out. Me and one client would play scrabble together every day. I always felt like I was doing something wrong when I was playing scrabble. But I remember my boss telling me that I was there to have a positive affect on people, to be present and have relationships, and that if me and this person felt good about playing scrabble that totally fit within my job. These are the low expectations. There were also very high expectations in terms of deescalating very intense situations and interacting with individuals that were both experiencing psychosis and presenting hostilely. (I think of a client who was delusional about being a lawyer and would 'use the phone' for some time each day to work on her cases. There weren't any actual cases. At one point another (more lucid) client needed to use the phone and she was 'using' it. I think he took it from her, she was upset, and came to find me. I tried to negotiate for her to have some time to 'use' the phone. He said 'Man, you and I both know she's not actually talking to anyone!' I empathized, "I know... I know..." and negotiated some deal where both parties could be appeased. Wild stuff, real human situations).
I didn't stay at this job long enough to really internalize all this about presence. I am still making sense of it.
I had a similar experience in my graduate school internship when I was working with intellectually and developmentally disabled folks. I mostly ran groups, but also did a fair amount of 1 on 1 work (especially with non-verbal people). Groups were chaotic at times. I would often have 12-20 people in a room with vastly different presentations. In the same room I'd have people living with: traumatic brain injuries; schizoaffective disorder along with learning disability; downs syndrome; autism; and a variety of vaguely defined intellectual disabilities (mild, moderate, severe, a la the DSM).
I was doing my best to be therapeutic with these folks, but that meant hanging out, eating together, doing puzzles, playing games, making jokes, gesturing, playing. I requested to work with non-verbal individuals because I was working on getting deeper into my own body. I worked with one guy in particular that was often disruptive during groups. He was a big dude. His language was super limited. He was really eager to interact with others, but he didn't understand how big or strong he was. I noticed how disruptive he was in groups and I offered to take him out for walks during those times. We would walk together in a 3-5 block radius, encountering lots of things: mail carriers, overturned trash bins (which he insisted we clean up), dogs, people. I had a lot of fun with him and was surprised by the depth of our communication. No words, or very very few words. Lots of gesturing, lots of moving together, lots of pointing and groaning: "Ah! Aha! Mmmmm..." We were just walking.
With other clients I would paint, listen to music, or just talk. In groups I would talk about emotional regulation and social skills, but I was really trying to get people to interact with one another and tell stories. This was also my approach during my groups during my forensic job. I ran a 'socialization and social skills' group. I really leaned into the socialization part, I just wanted to talk to people and get other people talking to one another.
These experiences introduced me to the irreducible importance of presence. Presence is not flashy or fancy. It is hard to even see it. But sitting and playing scrabble with someone, walking, painting, listening to music, really being involved and connected while doing these things. The depth of it is strange. I'm trying to write about the deep experience of being close to people that I didn't really speak with. It is hard to write about, and now I'm merely gesturing at it.
I want nothing more than to be close to actual people that I can touch and talk to. I see nothing so important in life as other people and my relationships with them. Tonight I was hanging out with a friend and I told her that the things I've published don't feel real compared to my living relationships. I had dinner with her and our other friend, celebrating a recent success of his. That feels real. These two people that I've come to know and love, having a nice meal together to celebrate a victory. We talked about how it was a relief and how it was hard. We've all been going through it this year.
The meal is nice and costs money but relationships can't be bought. Even therapy, which is paid for, is contingent upon something other than the money to actually happen.
I'm comparing this sense of presence to other ways of being that are more technical or control oriented. Presence, as I'm using it, is about allowing or welcoming aspects of an ongoing process. Other ways of approaching life are more managerial or defensive: we want to predict, plan, and control. Technical ways of thinking of course have their place in life. I still predict my routes when I travel and use a calendar to plan my days and weeks.
Sometimes presence can be lost in this technical orientation.
It was relatively easy for me to present during my internship because I was settling into the fact that I'd glimpsed in my first mental health stint: it is okay, no, essential to be present with people when working in any therapeutic capacity. I suppose I don't mean merely present, as in just a physical body plopped into some physical space. I mean real presence, one soul genuinely interested in and actively attuning to another.
After my internship, after graduation, I got a job in forensic mental health. I was working with clients who were either exiting incarceration or avoiding incarceration. Part of their conditions of exit/diversion was court-mandated mental health treatment. As you might be able to guess, a lot of these people weren't very happy to be speaking with me. This made sense. As far as they know I'm just another manipulative person working the mysterious levers of the manipulative institutions they'd been navigating for god knows how long. They have no good reason to trust me. And, to be fair, as a matter of course I was plugged into a variety of monitoring and reporting systems. I was required, for example, to complete 'compliance reports' for probation officers of mental health court clinicians on a monthly basis. I was required to be a narc (unless I found ways to be creatively compliant rather than merely conformist).
I therefore had to spend a good deal of time and energy gaining people's trust, essentially undoing or working through the expectations put upon me by the role and situation. It was very hard to achieve presence with client's in that environment. The entire situation is so inherently unsafe, taking place in such manipulative institutions, how could you possibly be presence? It is worth saying explicitly: in my understanding, presence requires a sense of safety (in the deepest and broadest sense. Not just physical but emotional and personal safety).
The whole forensic environment was far more technical than my current therapeutic situation (a lovely group practice). I remember when I got to this practice I was shocked that people just wanted to talk to me. I had gotten so used to doing so much case management, so much reporting, so much bureaucratic and institutional work. Suddenly I have a single person in front of me that just wants to talk and for me to listen and interact.
It is in private practice that I've been able to understand presence more fully. I've been writing a lot about, maybe I'll post some of it.
But I'll just note that there is some tension between presence and having a technical orientation towards life or its problems. My experience in forensic mental health leaves me comfortable claiming that institutions become most technical when it is punitive, manipulative, and aimed at control. I think I'm passing my experiences through the new perspective I have from reading Illich and going further.
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