Even after 35 years of working in mental health, I still get a little nervous when I am calling a provider I don’t know or have never worked with to coordinate services. It’s not that I don’t value sharing information, I just find not everyone has the same philosophy and not everyone welcomes an opportunity to collaborate. Or, there are those who are willing to collaborate, but whose definitions of collaboration are different than mine.
When Coordination Becomes Supervision
Callie was referred to me by her psychiatrist who had been prescribing medication for a few months. She and her husband were also referred to a couples therapist. Callie had a long history of anxiety, peppered with short periods of mild depression. She had been in therapy several other times in her life and found those experiences to be helpful. She was bright, insightful, motivated, and was looking for strategies to manage panic when it arose, along with a greater acceptance for those short periods of mild depression.
She and her husband were in couples therapy to address conflicts around parenting. They were in their mid 30’s, and in the five years prior to beginning therapy, they had twins, and then two years later a third child. After having been married for 10 years, they had developed a rhythm in their marriage that three small children were straining. The stress they were experiencing was understandable and, according to Callie, they sought couples therapy to communicate more effectively around parenting, and to find ways to salvage some of the intimacy they had prior to the arrival of their three children.
After seeing Callie for several months, we discussed the possibility of me talking with her couples therapist. I thought it might be helpful for us to coordinate our work to support both Callie and her husband in this period of change. I wanted to reach out to talk about my work with Callie and to share what I thought she was bringing into couples work from her history. While I didn’t know the other therapist, I thought providing more information about Callie could do nothing but help in his work with the couple.
After several back and forth voicemails, I was able to connect with Callie’s couples therapist. Before I had a chance to say anything about my work with Callie, I was offered recommendations about how I might proceed in my work with her. “I’ve seen the couple for five sessions,” the couples therapist reported. “And I think Callie needs to see you twice per week instead of once per week, and you need to be working on her history of abuse. I see her as being quite resistant to therapy,” he continued, “and she says you two are not addressing her past.” I had prepared myself to share information and talk about how we might work together, but I was totally unprepared for supervision, especially from someone with whom I’d never worked previously.
He continued to provide me with additional recommendations about how I might work more deeply with Callie and despite my attempts to share my thoughts about our work, it became clear that this call was not about coordination but was instead about me hearing what the couples therapist thought I should do in Callie’s individual therapy. I stuttered and stammered and felt myself becoming more and more inarticulate. The call ended with an invitation to call again if I had more questions. Click.
When Collaboration Becomes Reenactment
Rick was in a group I was facilitating for survivors of childhood sexual abuse. His father had sexually abused him for over 10 years, and his mother alternated between being neglectful and being verbally abusive. To add to Rick’s childhood experiences of abuse, the conflict between his parents was extreme but never verbalized. Consequently, he grew up in a home that was abusive, neglectful, and silencing.
I’ve found it incredibly helpful for people in the survivor groups I’ve facilitated to be in concurrent individual therapy. I also ask that people sign consents to exchange information so that I can collaborate with their individual therapist while the group is running. In Rick’s case, he was in individual therapy before even beginning the survivor group. He’d been working with Rachel, his individual therapist, for several years. He readily signed the consent and before the group began, I called Rachel to introduce myself.
When I’d not heard back from Rachel after the first meeting of the group, I reached out to her again and left a longer voicemail, again introducing myself and sharing more information about the structure and process of the group. I left both my office phone number and my cell number. After a month had passed, I’d still not received a return call from Rachel.
Shortly after my third attempt to contact Rachel by phone, Rick came to group one evening and shared with me, in front of the other group members, that his individual therapist didn’t believe in talking with other therapists. Instead, she asked that Rick find out from me what I wanted her to know and that he would then share it with her. I thanked Rick for relaying this information, slowed my breathing, and facilitated the remainder of the group.
I immediately called Rachel, trying to determine if this is what she actually shared with Rick, but was only able to leave a voicemail, which was never returned. Whether intentional or not, Rachel and I were now in the position of reenacting the lack of communication between Rick’s parents, and possibly increasing the tension Rick experienced around attachment, betrayal, and allegiance.
For the remainder of the group I tried as much as possible to work collaboratively with Rachel only through Rick’s reports. I listened as Rick reported what Rachel had said to him and I tried to find ways to support her insights or to thank Rick for sharing them. More than anything, I wanted to find ways to create an experience in the group that didn’t recreate the dynamics Rick experienced in his family. Without speaking with Rachel directly, this was extremely difficult and, I’m sure, sometimes impossible.
When Collaboration is Delayed
Whenever I discuss a possible medication evaluation with a psychiatrist, I talk with my clients about my rationale for bringing up the idea of medication and also offer to talk with the psychiatrist prior to my client’s first appointment. Most of my clients have appreciated this offer, often telling me they would like for the psychiatrist to understand what they have been working on in individual therapy. Most also tell me they hope my talking with the psychiatrist will also help them feel more comfortable when they arrive for their first appointment.
Andre was no exception. He had a history of depression and had never taken any kind of anti-depressant medication. When we discussed the possibility of medication, he was open to the idea and even excited by the possibility that there may be another way to address his pervasive sadness. I gave him the names of several psychiatrists and also offered to talk with whomever he chose to see prior to his first appointment. “Please call me and let me know who you’ll be seeing,” I offered, “and if you want me to talk to the doctor prior to your appointment, I’ll send you a consent to exchange information and I’ll make the call.”
When it came time for Andre’s next appointment with me, he said he had already seen the psychiatrist. “When I called her I said I wanted you to talk with her before my first appointment,” he explained, “but the psychiatrist said she wanted to meet with me before she had any information so that she could formulate her own opinion.” I was sure Andre could see my face flush. “She prescribed prozac and then also recommended I take klonopin at bedtime,” Andre finished.
It’s quite possible that this doctor would have prescribed these exact medications had I spoken with her prior to Andre’s appointment. Still, the idea of meeting with him knowing I’d been seeing him for close to a year and not wanting to talk to me about our work together (and knowing this was something Andre also wanted), felt dismissive of me and disempowering of Andre.
When Collaboration Becomes Synergistic
Despite experiences when collaboration doesn’t hold the same value with others as it does with me, or when it is defined differently, there are those experiences when the power of collaboration has immediately powerful consequences.
I met my current business partner, Bruce Koff, because a woman he was seeing individually had decided to enter a group I was facilitating for women survivors of childhood trauma. Before Elizabeth had entered the group, I received a call from Bruce introducing himself and inviting me to lunch to discuss his work with Elizabeth for the four years he had been seeing her.
When we met for lunch, I learned about Elizabeth’s vulnerabilities and her strengths; what she had worked on with Bruce, what he had found helpful, and where he had unwittingly walked into territory with her that had triggered painful memories and flashbacks of abuse. His insights were immensely helpful to me in my work with Elizabeth and, for Elizabeth, knowing Bruce had spoken with me created an initial sense of safety that allowed her to set foot in the room the first night of group.
As the group progressed, Bruce and I remained in contact about Elizabeth. Her knowledge that we were working together to support her; that two people were so invested in her that they spoke about her regularly, was in itself healing. And when the group concluded, whenever Bruce was on vacation, I was the person Elizabeth would see in his absence. There were even times when Bruce wasn’t on vacation, that something came up in his work with Elizabeth that somehow felt related to her experiences in group or something she told him she wanted to speak with me about. He consistently encouraged her to make an appointment with me, which she did without hesitation.
As our work with Elizabeth continued, we also invited a massage therapist to join our team. Becky Crawford was a colleague of mine from several jobs prior. She was a sensitive and skilled body worker who knew how to do body work sometimes even without the use of touch. Conversations Becky had with Bruce and with me helped her understand Elizabeth’s needs and helped Elizabeth see Becky as another person she might be able to trust. There was even an occasion when Elizabeth met with the three of us together for a session. Our willingness to work together, on her behalf, created a synergy for healing that none of us alone could have come close to creating.
Collaboration is About Relationships
One of the reasons I became a social worker was because I believed that to fully understand any of us, we need to understand our context, which includes the people with whom we have relationships. “Person in environment” is a phrase I learned in my first social work class, and while I may not use those exact words today, the meaning behind them serves as the foundation for my work.
Even when I am seeing only one person in a family, there may be occasions when I explore inviting other family members in for a session. Of course I talk with my clients about the rationale for these choices, and in instances when the safety of my work with someone may be compromised by inviting in another person, that takes priority. When safety is not compromised, however, the opportunity to see my clients in relationships with significant others has often expedited therapy.
I believe the same can be said for collaborating with other service providers. If I am working at cross-purposes with others with whom my client is working, I can’t be working in the service of my client. There are extenuating circumstances when collaboration should not occur if it compromises my clients’ safety (e.g. domestic violence). But when safety is not compromised and my clients seek and want the support of collaborating providers, there can be powerful synergy.
Sadly, Elizabeth died unexpectedly many years ago. She never had a diagnosable illness, but all of us believed the years of abuse she had endured took their toll on her immune system. As her funeral service began, Bruce sat to my right, and Becky to my left.
“We shape our self to fit this world and by the world are shaped again. The visible and the invisible working together in common cause, to produce the miraculous.”
David Whyte, “Working Together”
By Jeff Levy, LCSW, CTRS