We Need Not Be Fine: A manifesto for mental healthcare workers who can’t go on like this
Consider the rhythmic moment we all know well: the client arrives and is situated across from us — or, these days, on screen — there is a pause, perhaps an acknowledgment of arrival. Some therapists begin each session with a predictable welcome, others wait for their clients to start where they are. Because we are all humanly accustomed to inquire, and because life is so unrelenting right now, the question is often returned to us, “How are you?” And we know what we believe upholds the client-centered dynamic: “I’m fine,” or some equally neutral response, our true state of being purposely eclipsed. Are any of us truly “fine” given the unprecedented collective suffering in recent years?
Relational clinical consciousness articulates that clients can and will know us, but our clinical inheritance demands we uphold that they never feel us. In this beginning moment of inquiry, in which the client is presumed to arrive in an “unwell” state, and in which we project back our own professionally-constructed state of perpetual wellbeing with impersonal pleasantries, we set the terms of the encounter. We are often presumed to be beyond reproach and therefore prepared to offer the ideal curative, but do we consider the unintended harm our internalized obligation to minimize our embodied personhood might cause?
By verbally evacuating our own complex bodies of need, discomfort, and pain each week, we enact it is possible to be well constantly, which in turn creates unrealistic expectations of bodymind* absence. This impossible standard, rooted in ableism and toxic professionalism, fails to model generative curiosity and care about our own holistic being and its needs. In this stance, we enter into an unspoken contract with clients in which the simultaneity of bodily complexity can not be navigated in the dyad.
Clinicians who treat cumulative developmental trauma attempt to model reparative attachment, offering what a client has never before experienced from a care relationship. This attempt at idealized caretaking may in fact tend towards pathological altruism, in an effort to facilitate the reception of unidirectional care. In doing so, we present a misguided and even harmful template for intimacy. While the impulse to transmit our capacity to fulfill clients’ unmet infantile wishes is understandable (and mutually momentarily satisfying), when repeatedly enacted, we find ourselves stuck in an obligatory, unsustainable performance.
If we encourage a client to believe it is possible to return to a symbiotic state, rather than support them in grieving the loss of all encompassing care — a desirable attunement that is not achievable beyond the womb (if ever) — we fail to prepare a client for moments when the relational object inevitably cannot uphold their stance of irreproachability. It is precisely in the mutual recognition of the therapist’s unwellness (something that is often felt by a client, but remains unmentalized unless the therapist acknowledges it) that we allow a client to see humanness mirrored. The belief that it is necessary to suspend one’s own needs in service of the client feeling wholly attended to, and to expect rupture when we cannot indefinitely pause our bodies, creates, in essence, an anxious attachment for the therapist, and likewise implies that the client may be incapable of mutual relationship.
As therapists, our bodyminds are our instruments, and capitalism encourages us to believe they must be flawless to be effective. We are encouraged to perform ablebodiedness, until we cannot. Many clients, based on how our profession has packaged and presented our role, experience our shift into unwellness as a “downgrade” — furthering the notion that being disabled is worse than not, and that a disabled caretaker can never offer the equivalent (or greater) care as a non-disabled one. If a client is themself disabled, becomes disabled in the future, or experiences a part of themself as different in ability or acceptability (most of us have those parts), we communicate to them that to be worthy, they must hide, mask, or perform. This confluence of shame and unrealistic expectations of ‘health’, on the part of both therapist and client, limits the potentiality of the clinical relationship.
Our chronically ill therapist bodies are already failing to cooperate with these expectations. It was only in our individual experiences of frequently confronting, over many years, our own bodily disruptiveness that we came to recognize the necessity to expand the interpersonal field to not just welcome, but require the embodied experience of client and therapist as constitutive of the healing relationship. In her blog, Leaving Evidence, disability and transformative justice writer and activist, Mia Mingus, writes, “Access intimacy is something I am coming to understand that I need in my life; something that I cannot (and don’t want to) live without. I need it to literally be my whole self… Without it, relationships exist under a glass ceiling or split by thick frosted windows, with huge pieces of myself never being able to be reached. Without it, there is survival, but rarely true, whole connection.” To be seen, heard and felt has to be a reciprocal practice.
When we cloak our full human experience in the name of professional competence and rigor, we disarticulate our wholeness to replace the parts that do not fit those of the archetypal therapist: white, cisgender, heterosexual, non-disabled, neurotypical, straight-sized, class privileged, etc. We designate our masked parts as undesirable in their disavowal. What we share willingly of ourselves implicates what is of value and what should be hidden or discarded. In this, the therapeutic relationship upholds multisystemic oppression, causing harm to us as a collective body. The shame that leads a disabled therapist down the shadowy corridor of internalized ableist action, in which we contort our bodymind in an attempt to give light to the able-seeming, societally accepted parts, is not paranoid. When a client experiences the impact of their therapist’s disability, it may well be experienced as a concern — are we not reliable? Only some clients may be able to identify the ableist, white supremacist urgency at play.
These fears are fruit of the poison of capitalism and a white supremacist heteropatriarchy. They do not belong to our clients, nor to us who commit the same microinvalidations with our own therapists and colleagues. They are, however, our collective burden to dismantle. If we, the care providers, who even in our shame hold power in the room, agree to be split by this fearful subordination, we validate the same toxic legacy that inhibits the growth and healing we dedicate our bodily instruments and our lives to offering.
So, beyond disruption, what potentiality would open up if therapists were to answer a client’s inquiry as to how we are with something transparent? We have directly experienced the healing possibility that emerges when therapists are seen as imperfect, and simultaneously, capable of radical care. We have canceled, shifted to phone sessions, shared health updates that dictate different access needs, used heating pads in session, excused ourselves mid-session, taken short and long term leave, and terminated due to illness. Many clients initially become anxious or experience the potential “downgrade” of care, but eventually, most clients recognize that none of this is a catastrophe. Some even experience our self-tending as “exciting and relieving, like a long slow exhale”** — feeling validated and encouraged by our humanness.
Quite often, in this, our clients have experienced a different relational outcome than their attachment wounds might lead them to anticipate. A client may be able to recognize that we attended to them in ways that their caretaker(s) never did, without banishing our wounded parts of self. Even if we have to fade or go away temporarily, the outcome (newly discovered forms of flexible intimacy) is different than the childhood attachment wound (abandonment). These illuminating moments are reparative and evoke the “care linguistics” and “care fluency” defined in conversation between Leah Lakshmi Piepzna-Samarasinha and Teukie Martin (Piepzna-Samarasinha, 2022):
Coming from an understanding of access and care as a dialogical process, where both the asking and offering of care is iterative and cyclical, I am offering “care linguistics” as a way of understanding this emergent practice amongst and between crips. Care linguistics honors multimodal forms of communication. . . I may take on something I learn from you, you may transform something you learn from me. Through this process we develop a “care fluency” as both providers and recipients of care. Every care interaction is an opportunity for deeper learning and understanding– we become more skilled and confident in navigating our own needs and the needs of others.***
What if, in our transparent not-fine-ness, our clients learn to experience care that demonstrates tenacity through challenge? Our clients may come to recognize their capacity to experience physical shifts without emotional evisceration not in spite of, but as a result of, the embodied presence of “unwell” states. In our refusal to be ‘fine,’ we extend a mirror and rare opportunity for our clients to sense into their own struggle as a place for, not an impediment to, healing.
* This term was integrated into disability studies literature by Margaret Price (Price, Margaret (2014). “The Bodymind Problem and the Possibilities of Pain”. Hypatia. 30 (1): 268–284) and taken up by many other disability justice writers and activists including; Eli Clare (Clare, Eli (2017). Brilliant Imperfection: Grappling with Cure. Durham: Duke University Press), Sami Schalk (Schalk, Samantha Dawn (2018). Bodyminds Reimagined: (Dis)ability, Race, and Gender in Black Women’s Speculative Fiction. Durham: Duke University Press) and Leah Lakshmi Piepzna-Samarasinha (Piepzna-Samarasinha L. L. (2018). Care work : dreaming disability justice. Arsenal Pulp Press).
** Mia Mingus, “Access Intimacy: The Missing Link,” Leaving Evidence (blog), 5 May, 2011, https://leavingevidence.wordpress.com/2011/05/05/access-intimacy-the-missing-link/
*** Facebook Messenger conversation between Piepzna-Samarasinha and Teukie Martin (2022). Interdependence is not some giant living in the hillside coming down to visit the townspeople: the church of show the fuck up, in real life. In L.L. Piepzna-Samarasinha’s The future is disabled : prophecies, love notes and mourning songs (p. 100). Arsenal Pulp Press.
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