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Dispatch from the front lines: A week in Head Start

I spent a rather frantic week in Iowa last week. I know, that does sound sort of paradoxical. I’ll explain: I was collecting the last bits of data for a study I’m conducting in a collection of Head Start spots in Iowa. This required a lot of riding around town, zipping through various schools and agencies with a formidably energetic and connected special education interventionist, plus a good deal of running around (literally) behind preschool teachers begging for interviews. It was a grand time. We have some good-looking data, which we’re hoping shows the promise of a play-based intervention we’ve been using for eons but haven’t ever bothered to quantify before.

In any case, while running to and fro last week, I had some remarkable moments with preschool students and teachers.

  • A miniature United Nations (one boy from Somalia, one from an Arabic-speaking middle eastern country, and one White U.S. born) of preschool boys managed to agree on and build a huge tower of blocks, and did not fall into cultural divisions when it all fell apart.
  • The terror! A three year old boy expressed great horror at the “yellow spider” his teacher drew on the white board. The fact that she called it a sun made little impact.
  • The tenderness and care children can take with each other when taught how to do so.
  • Enormous numbers of smiles and hugs that greeted us in every place we visited.
  • Surprise when I found a man(!) working as a teacher in one of the rooms. The children clearly loved and respected him, and he clearly reciprocated.

At the end of the week, all worn out from getting up and down from the floors of various classrooms, running around town, and investing great amounts of energy and worry into the examination of raw data, I was once again reminded how important Head Start is to the educational system in the U.S. Head Start is celebrating 50 years this year. It was one part of the vast War on Poverty instituted by President Johnson in 1965, and is arguably the most successful of the programs begun then. It’s certainly impacted the greatest number of poor Americans of any of those original programs.

In more recent and less charitable years, HS, along with every other educational or human services-oriented government endeavor, has met with funding cuts and reductions in support by politicians. We’ve had a period of austerity of compassion for about 20 years, off and on. Head Start has demonstrated its importance hundreds of times over 50 years, including studies that show better educational outcomes in adulthood for kids who went than for those who didn’t. But these programs are expensive, according to our current batch of elected officials. Never mind that the entire budget of Head Start is less than some of the line items including in the defense or federal prisons budgets, it’s still been a target for cuts lately.

Just this week, Pope Francis moved Oscar Romero along the path to sainthood, and he had a little chat in his office with a liberation theologian. Liberation theology has been unfashionable for about 30 years now due to its emphasis on possibly communist ideas like helping the poor and needy. Although His Holiness isn’t an elected official in the US, I’m hoping that the return of the Vatican’s attention to the poor and least signals a larger cultural sea change in the gaze of the public, from the austere and uncharitable Bush II years to a more pro-people focus redolent of the 1960’s, except with data and technology.

The Vatican seems an odd place for a revolution against greed and repression to begin, much like Iowa seems an odd place for a vacation. Let’s not count either one out just yet.

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Self-regulation, toxic stress, and Baltimore.

On first sight, you might think that the title of this article leads to one of those four-part pictures from Sesame Street entreating you to decide “Which One of These Things Doesn’t Belong”. Actually, all three of the subjects in the title do go together, it’s just uncomfortable to confront that knowledge.

So, let’s break it down.

Self-regulation is a set of skills that stretch between the domains of cognition, emotion, and and behavior that allow adult humans to make good, prosocial, rational, decisions even under stressful conditions. This group of abilities is based on healthy brain development in the early years, which is fueled by good-enough parenting, and the meeting of the basic physical needs of food, water, and shelter (there is some debate about which is most damaging to forfeit, and the front runner may be the parenting). When things go right for a baby, s/he develops the capacity to regulate her own emotions, thoughts, and actions well enough to fit in socially and survive to adulthood. When things don’t go well, self-regulation may be delayed or halted in one or more domains. A kid or adult with crap self-regulation abilities might appear hostile, aggressive, violent, smart-mouthed, withdrawn, anti-social, hyperactive, lethargic, or unfocused. Other things can cause those behaviors, but quite often, self-regulation is the real culprit, especially when kid is exposed to what’s called toxic stress. Here is a recent research brief about this little combo, read it if you want more depth that a blog post can provide: http://www.acf.hhs.gov/programs/opre/resource/self-regulation-and-toxic-stress-foundations-for-understanding-self-regulation-from-an-applied-developmental-perspective. It’s fascinating.

Toxic stress is different from everyday stress in terms of frequency, intensity, and duration. Most people have some aggravations, annoyances, and frustrations every day. Folks with toxic stress have catastrophic, life-threatening, chaotic, terrifying stress every day, all day. Toxic stress is a nightmare for anyone trying to develop or maintain mental and physical health. There’s a mountain of evidence about ACEs (Adverse Childhood Experiences) and the nasty things too many of those can do to a person over time. Check out the ACE home page for the numbers: http://www.cdc.gov/violenceprevention/acestudy/

Lastly, Baltimore (and Ferguson, and North Charleston, etc. etc.).

The (White) police have been shooting up Black folks again. That this happens isn’t news to most people. That it is continuing to happen so often and that so many local jurisdictions haven’t done anything to assess or change the systems that set up the circumstances that foster these murders is shocking. For Black and brown people living in places with a high load of toxic stress, that’s the last straw. Toxic stress is literally poisonous. Chronically elevated levels of cortisol and other stress hormones cause the kidneys, heart, and lungs to overwork. Soft tissues like veins and arteries wear out early. In childhood, people exposed to too many ACEs face an uphill battle towards mastering self-regulation in all three domains. Regardless of gender or race, a person growing up amidst toxic stressors develops self-regulation later and less broadly than the same person would in a more safe and stable place. When an adult with a high toxic stress load and low levels of self-regulation is attacked, threatened, or in a hostile-seeming situation, he or she is more likely to react with violence and aggression than a person who lives somewhere safe.

This is not to say that adults shouldn’t be held responsible for damage they do while enraged. However, in places with high levels of toxic stress, no one should be surprised when the proverbial shit hits the fan when yet another citizen is murdered by the police. One of many reasons that the death of Walter Scott in South Carolina and Freddie Grey in Maryland provoked such extremely different reactions from the public was the response of the people who were perceived to be in charge. Although both cities have high levels of toxic stress, the officer who killed Scott was immediately arrested and fired from the force. In Baltimore, no arrests have been made, no announcements from the authorities have been made about suspending the officers involved, and it seems to the citizens there that no one cares. Both cases are obviously tragic and have provoked anger and grief in their respective communities.

In Baltimore, people who are already tired of not mattering have been reassured that they don’t. In North Charleston, it seems that the police force has found a way to communicate to its people that they do matter. When you’re already up against a wall, the last thing you need is someone to shove you up to it harder. That’s when people, many of whom are already short on patience, break. The limbic system essentially stops asking the upper levels of the rational brain for input, and action takes over from reason.

I wish I could close this little rant with some smiley sentence about things getting better. I am glad that Science has now empirically validated how important early environments are to healthy adult development. I am grateful that interventions for schools and clinics are in the works to help stressed out kids learn to self-regulate earlier and better. I’m left wondering if any of it matters.

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Revisiting the sham of culture: Public school edition

Last night in our training clinic, I watched one of our grad students conduct an intake interview with a 17 year old who was recently expelled from school. The idea of expelling kids from school makes me ill to start with, so I watched with a grumpy face. As the session unfolded, I only felt more angry and irritated. This 17 year old kid told the grad student that he was being expelled over, “a lot of little stuff” like tardies, disrespecting teachers, not doing work, etc. I’m not naive enough anymore to buy that story without checking it out with the school, but it was still disturbing. It could be true.

To complicate matters another step, this particular kid is Black, big for his age (athletic big, not fat big) and wore his hair shoulder-length and braided. He spoke very quietly, even after his great-grandmother, who is his guardian left to return to the waiting area. I could easily imagine this guy could scare the crap out of a teacher without really trying, just by being so tall and muscular. But being scared of a kid because he looks like he could tackle you with one arm doesn’t make it ok to throw him out of mainstream society.

[Didn’t you know that’s what expulsion is? Read more here: http://www.ed.gov/news/press-releases/expansive-survey-americas-public-schools-reveals-troubling-racial-disparities]

I know the U.S. government in general, and the states in particular don’t quite comprehend the problem, but it’s really pretty simple. Here’s the deal, in a simple geometry-ish proof:

1. There is a strong relationship between school failure and life failure (e.g., going to prison).

2. Some kids are at much higher risk than other kids for school failure. We know who they are. We’ve known this for decades (poor, black or brown boys, little to no adult support at home, bad neighborhoods, toxic stress, abused, neglected, and generally stressed out kids).

3. We know that when kids in #2 are given certain types of early and frequent intervention, they are much less likely to fail at school.

4. If they don’t fail at school, they have a hell of a lot better chance at staying out of prison.

5. If they don’t go to prison, they can get jobs. If they work, they pay taxes.

6. If we spend a little money now on those interventions in #3, we will have greater tax revenues in the future.

7. Investing in appropriate educational interventions for stressed out kids literally pays off.

QED, asshats in office. We need intervention for stressed out kids. We need it early. We need it often. We can not wait.

Back to the kid in my opening paragraph. I really hope he comes back. He said he would, but in my experience, it’s about 50/50 with adolescents in trouble who live with folks who aren’t their parents. Great granny looks like she’s about 80. I don’t know that she has the energy to make him get his act together. The kid seemed interested in doing things differently, but also seemed very doubtful about being able to make it happen. I fear we’ve lost this one, mostly due to this dubious expulsion. It’s way past time to stop expulsion.

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Thump thump thump….here come the helicopters (parents)!

One of the great joys of being a professor in a graduate program is watching as young adults grow into creative professionals from being ex-college-students. Every fall, we welcome a group of twelve or so young people, most of whom graduated from their undergraduate programs mere months prior, to campus. Over the next two years, we do the sometimes difficult work of molding them into capable, responsible, and confident beginning therapists. When they leave after graduation, most of them go on to lead rewarding, full, and pro-social lives.

The two years between the arrival of newly-minted B.A. holders and the departure of newly-minted M.S. holders can be tough on everyone involved. Learning to be a competent therapist isn’t easy. The content material; diagnostic categories, pharmacology, neuroscience, counseling skills, theories, and techniques can be overwhelming. Learning to make meaningful connections with total strangers who have lives very different from your own can be exhausting. Developing an identity as both an adult and a professional can be the most difficult aspect of the entire process, especially for 23 year old students whose parents don’t identify as professionals.

The notion of professional identity has been belabored for years in the counseling literature. How do you “be” a counselor? How, if at all, is that person different from who you are at home or with friends? How do you put on this new identity without loosing sight of your former self? Students can struggle mightily with all of these issues, and as much as faculty and supervisors want to help them, it’s a battle each person must face on his or her own.

An interesting cultural turn has recently made this struggle more difficult and less likely to resolve by the time the students leave us. Their parents are now jumping into the graduate program, sometimes at the invitation of the student, but just as often not. Comedians and pundits have talked for years about the silliness of millennial parents over parenting their children to the point of the absurd. Children are no longer left alone to explore the outdoors, even in safe neighborhoods. Parents go to high school dances. They go on graduation trips. They heckle college professors who “give” their child a B or lower.

And now they’re coming to graduate school.

I’ve heard from colleagues around the U.S. that they’re now being contacted by the parents of students about a range of issues, from admissions to internship placement to graduation requirements. Last week, I had my first experience with a parent of a graduate student interfering in the student’s educational experience. I was stunned, to say the least.

And now I’m sad, mostly for the student. The early twenties aren’t easy for most people who are making big transitions from a late adolescent stage, which is drastically extended in modern culture by the university experience, and early adulthood. At the point in their lives when young people most need to wrestle with issues related to independence, freedom (and it’s twin, responsibility), and adult identity, parents are figuratively putting their feet in the doors of development, halting or delaying the process of maturation immeasurably.

I am glad this student’s parents love him/her and are supportive of the journey of higher education. I wonder if they realize that without allowing any struggle at all on the part of the student, they are effectively retarding his/her transition into adulthood. I’m hoping that the parents will learn to allow the child to work through the difficult passages of life with much less interference in the future; I can’t imagine mom or dad calling the boss about a workplace issue, but I guess it’s very possible in the current climate.

It’s my own generation of parents that are crippling their children by eliminating rehearsal for adulthood by removing all obstacles. And it’s us who will have to live with the way we’ve so poorly tended our duties. I’m left hoping not to have to talk to the parents of my doctor before s/he will give me my pills in the old lady’s home.

It’s our mess, X’ers. We need to fix it before it ruins us all.

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The proper care & handling of the highly gifted individual

One of my favorite stories about my Dear Spouse from his mother goes like this: When he was in kindergarten, the teacher expressed concern that since he rarely talked in class, often stared out the window for long periods, and didn’t always do the “work” the other kids were doing, he must be mentally challenged. Mommy knew that this was totally wrong,but instead of telling the teacher that she, herself, was the mental midget in the equation, Mommy called a psychologist friend and had her give DS an IQ test. Turns out, he’s a genius. Mommy 1, teacher 0.

More recently, the youngest child of Dear Spouse has faced his own set of challenges within our beleaguered public school system. Said child, who has just started that horror show called “middle school” is really not a fan of busy work. His philosophy is that if he can make an “A” on the test, why does he need to do a dozen problems for homework every night?

In this age of strained school budgets and high-stakes testing, gifted kids have completely been left by the wayside. Outside of a very few remaining state math and science academies, there is almost no place in the average public school corporation to nurture young smarty pants-es. You’d think with the big push for more STEM graduates, school systems would be stepping on themselves to create the best possible incubators for young geniuses to explore their minds and worlds.

Nope.

In our town, “gifted education” is determined largely by the parents lobbying the superintendent’s office for the inclusion of their young genius, and once added, the young genius is mainly treated to extra homework, not gifted- specific teaching approaches. The upshot is that the “gifted” class is full of doctor’s kids, professor’s kids, and kids of friends of the administration. Some of these students may actually be gifted, but mostly, they’re just privileged. In said “gifted” classes, the mostly White, all upper-middle class students do more homework than their less advantaged peers, and sometimes tackle more advanced subjects. In high school, they can take Advanced Placement courses which can lead to college credits for their work. This is, I fear, the norm in most U.S. school corporations, rather than a tragic aberration.

Truly gifted people are hard to define. It’s like porn, it’s hard to say what it is, but you know it when you see it. Back in the 1990’s, when we had rules about these things, to be placed in the gifted class, a kid had to score 2 standard deviations (about 30 points above the mean) above the average of 100. This means that only about 3% of the entire population of students should fall into that category, and that having rich and loud parents is not sufficient grounds for inclusion in the class.

I am not a fan of IQ tests, for a lot of reasons I’m not going to get into today. However, having some sort of standard aside from mommy’s letters and phone calls to get into the program seems like a better plan. Neither of the older children of Dear Spouse have had Black kids in their “gifted” classes, and certainly, no poor kids. I feel certain that there are smart Black and smart poor kids in our county, but they’re not being identified, which is tragic.

Nearly as tragic is the fact that the kids who are tagged “gifted” are not treated as such. The usual flat, old, worn-out, crappy pedagogy forced onto the masses are used with the “gifted” students, too. Lectures followed by guided practice, then independent practice, and a test, are the only teaching methods I’ve noticed at the middle school in any of the academic subjects. I’m not entirely blaming the teachers, some of them might have other, better ideas that are being squashed by the testing overlords, but that is certainly the only approach I ever see from the parent end of the scope.

Gifted people are not like the rest of us. Those folks who truly make up the 2-3% of the population whose brains are measurably more powerful than the rest of ours need different teaching, different parenting,and different job environments to truly shine. They wilt and wither under the standard teach and test models in education. They are terrible at following “because I said so” rules at home. They quit if the boss makes them go to a lot of pointless meetings.

Not all gifted adults are working for Google and riding around on hover boards or pioneering new brain surgery techniques. A shocking percentage (in my anecdotal experience) are sitting on a couch somewhere, smoking weed and working minimum wage jobs. A whole lot of them are working at slightly better-paying crappy dead-end jobs that come nowhere near challenging their prodigious intellects. It’s a sad fact that many highly gifted adults spent their k-12 careers trying to avoid extra homework, wondering why they had to do all the busywork if they could already understand the concepts, correcting the textbooks (this happened at our house this week), forgetting assignments that don’t interest them, skipping the dullest of classes, and not infrequently, dropping out. Many develop depression and/or anxiety due to the difference in how they view the world and how their family and peers view it.

If gifted kids are really lucky, they get born into families with other gifted folks. For example, Dear Spouse produced three more people as bright as he is. None of them are a breeze to parent, as is usual among the gifted. All three are completely different in temperament and personality, but all three also exhibit common giftedness-related annoying qualities to the parental units. They’re often forgetful of common sense things, like wearing a coat in the winter, don’t notice piles of laundry pooling around them (this might be a boy thing, too), can’t be bothered to do tedious repetitive homework, would rather read a novel in class than listen to a lecture they could give, and can make a hundred arguments against almost any task or chore. Luckily for them, they have parents bright enough to see through the nonsense and obstinate enough to make them do the thing anyway. And these are basically good-natured kids who have all of their basic needs met, and don’t live in an abusive or violent environment.

I’ve worked with several families over my career where this isn’t the case. Either the kid is so much smarter than the parents that s/he runs the house (which leads to anxiety because developmentally it’s wildly inappropriate) or the gifted child is so far different from the rest of the family that s/he grows up feeling disaffected and detached and lonely. Sometimes, these kids find better chosen families as adults and turn out fine. Sometimes, not so much- addiction is a problem of smart people from way back (see: Byron, Lord).

I’m not pretending to have answers to the problem of wasting the minds with the greatest promise in the service of the minds of more modest abilities. There is an entire body of literature about those things. I’m saying we need to DO  what’s in that literature to support and nurture those among us who might not fit the usual mold because they’re extraordinary and precious.

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Common factors versus specific ingredients in therapy: Who wins?

One of the Big Issues in psychotherapy is, and has been for ages, whether the common factors (empathy, trust, the therapeutic relationship) or specific ingredients (the techniques) are more important to helping clients get better. This argument rages on, especially in training programs. We have limited time with our students to prepare them to go out into the world and make it all better for everyone (which is not much of an exaggeration in how most of us see our mission). So, how best to spend our precious semester hours: focusing teaching on the common factors or the specific ingredients?

If research funding is any sort of barometer of importance (and I’m not sure it is), you’d have to conclude that specific ingredients are where it’s at- sorry, I am pathologically incapable of ending a sentence with “at”, so here’s a useless clause. Almost all of the funding coming out of the big federal programs at NIMH, SAMHSA, and NIH are targeted at finding out what, specifically, works for all sorts of people and their problems. Some of the big pushes are aimed at developing multi-modal programs, where, for example, you might have medication management alongside psychotherapy and job skills training for addicts. The programs aimed at research on therapy itself, however, tend to focus on the specific: determining if cognitive-behavioral therapy works for people with eating disorders, finding new diagnostic indicators for PTSD, deciding how long a person with depression needs to be in cognitive-behavioral therapy to get back to work, etc. All of the big federal agencies fund big studies with the hope of finding big answers to big questions, and their work is extremely important.

The findings from the studies funded by the big agencies, and private entities, often drive what insurance companies and Medicaid/Medicare will reimburse providers for providing. The idea, called “evidence-based practice” sounds like solid common sense: they’ll only pay you to do things that research tells us actually works. It’s supposed, I guess, to keep therapists from waving feathers around and chanting and getting Blue Cross to pay for it. I’m all for effective treatment, as long as that’s really what we’re looking for in the research.

Here’s the rub: all of the big studies funded by the big agencies with big grants, which are the bases for the guidelines for reimbursement, look at the small picture- the specific ingredients. And guess what? We’ve known for at least two decades now that the specific ingredients aren’t as important as the common factors in treating clients effectively.

There were a couple of Very Important meta-studies in the 1990’s (Wampold comes to mind) that pretty clearly showed that it matters a lot less what you do in therapy than it does how you do it. Of course, because all endeavors must have critics, the idea that how trumps what has its detractors. Most often, they claim that common factors, which are squishy feelings, can’t be said to be more important than “medical” interventions, like behavior charting and thought stopping techniques. The medical-model side of the house, which often controls the federal funding apparatus, seem to think it unthinkable that the major mover in therapy is the relationship.

I imagine there are a couple of reasons that common factors theory isn’t taken as seriously as it might be. One reason is the squishy-feelings aspect of the common factors themselves. How do you “empirically” measure such things as empathy, insight, clinical judgment, and connection (I have empirically in quotes because I don’t believe true empiricism is possible in therapy research, but that’s a blog for another day)? It’s far more simple to measure how depressed or anxious a person getting Treatment A is than his neighbor in Treatment B than to devise a way to measure how Therapist A connects or doesn’t with Client B versus Client C. The second, more insidious, and I imagine, honest, reason for the continuing popularity of specific ingredients theory is the basic struggle between the chalice and the blade, or the feminine side of healing being rejected by the more masculine side.

It’s not a popular (or possibly, wise) thing to do to say that our whole Western medical model, especially in psychotherapy, may be predicated on the repression of the feminine. It’s also not really where I was planning to go with this essay when I started writing it, but I think at this point, leaving aside the obvious conflict between empiricism and feminism would be cowardly of me.

I don’t have any solution for the common factors vs. specific ingredients divide, but I think it bears more investigation, and probably with a bit of irony and a slightly jaundiced eye.

As for where I’m leaving off in regards to how to focus time with students of psychotherapy, I leave that to the recently departed genius Miller Williams, an excerpt from the magnificent poem, “The Associate Professor Delivers an Exhortation to his Failing Student”.

If one Sunday morning they should ask you

the only thing that matters after all,

tell them the only thing you know is true.

Tell them that failing is an act of love,

because like sin,

it is the commonality within.

How failing together we shall finally pass.

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Graciousness

When I was growing up, manners were a Big Deal. Table manners, party manners, school and church and friend’s house manners were all bundled up together in what my mother sometimes called “home training”. Essentially, manners give us cultural reference points for how to behave appropriately for our class, age, gender, position, and culture. Because of my rather intense “home training”, I am able to write a damn fine thank-you note, host a cocktail party successfully, attend a wedding without causing a ruckus, and otherwise generally behave in a way that befits an adult White woman in the U.S. (especially the South, where manners remain a Big Deal).

While I’ve been roaming around India, I’ve had occasion to reflect on the role of manners in a global village. India is a very diverse and ancient place- the manners of the people here are traced back millennia, and can be quite complex and formal. For example, on the first day of our conference, the Chief Guest (a high-ranking bureaucrat from the University) was over an hour late. The opening of the conference was delayed until he arrived, at which time he gave a rambling, off-topic talk for another hour. No one left or began to talk to friends, or checked texts. Every single one of the 200+ audience members waited quietly and respectfully until he finally quit talking and left.

I cannot even imagine the depths of arrogance involved in being a person who thinks nothing of keeping 200 people waiting for an hour (he did not apologize) and proceed to ramble for another hour. My fellow Americans would’ve walked out, possibly after setting him ablaze.

Which brings me back to manners.

In my small experience, Indian people are intensely mannerly, to the point that I’ve begun to wonder if they might all be psychic. I think inside my head, “I’d love another cup of tea”, and it appears. Seriously. As a guest in an Indian home, you are not allowed to lift a finger to help your own self, no matter how stubbornly American-ly self- sufficient you may feel.

Really, manners generally boil down to displays of graciousness. In the West, this generally means helping guests, elders, and friends feel at ease. In India, graciousness seems to extend past helping others feel at ease to helping others feel a sense of being respected and valued, sometimes at the cost of the ease of the host. For example, if you say to your Indian host, “Wow, it’s hot in here”, you may find the whole family being organized into teams to fan you, or to fix the AC, or to otherwise insure that you experience no discomfort whatsoever.

The Indian sense of graciousness involves a level of self-sacrifice I’m not sure I can really grasp as a Westerner. An Indian person would far rather be hot, tired, out of cash, and foot sore than to have a guest do the smallest thing that might require effort. It’s a complete reversal of the usual power balance we see in the U.S.- here, the guest is not just made comfortable, he or she is made to be entirely without any cares of any sort for the duration of the visit regardless of what else the host may need or want to be doing. This appears to be true in homes of Hindus, Jains, Muslims, Sikhs, and any other religious or cultural group on the subcontinent.

Interestingly, this concept of complete graciousness to guests seems to extend to clients in the psychotherapy setting. I’m only beginning to put together the whole picture for myself, but it feels as if therapy here may be practiced with a natural sense of attunement and empathy that we work hard to cultivate in therapists in the West. I wonder if we all began to treat our clients as guests in our home rather than as paying customers involved in a business transaction if there might be a shift in the depth and effectiveness of our work?