NEVER HAVE YOU EVER?

Felt exuberant. Felt defeated. Felt physical or emotional pain. Felt confused. Forgot a name. Wondered if someone liked you, if someone hated you. Wondered if someone was thinking of you. Hoped. Felt repulsed. Felt betrayed. Felt disgust. Have you ever? Shivered in response to an unexplained sound. Felt someone’s eyes on you. Thought of someone lost to you through death or departure. Missed him/her/them. Grieved. Wondered about the universe, the meaning of life. The possibility of a hereafter—what it might be like. Felt empty; felt like a cliche. Had a ritual. Had a good luck charm. Felt mistrust; felt superstitious. Couldn’t get a song out of your head. Have you never? Cherished something. Cherished someone. Felt lonely. Felt loved. Experienced self-loathing, however brief. Saw a shape in a cloud, in the frost, in peeling paint. Anthropomorphized. Struggled to get out of bed. Felt different from other people. Felt transparent. Isolated, wept, couldn’t weep. Sought comfort, rejected it. Waxed nostalgic. Held one position so long that you couldn’t tell where one part of your body ended and another began. Felt that with a lover. Felt aroused. Climaxed. Obsessed. Pledged fidelity; changed. Felt rejected. Felt foolish. Felt your thoughts swirl, your heart race. Felt shamed by an internal critic. Struggled to draw breath. Saw or heard or felt something so beautiful, it hurt. So beautiful, it was almost intolerable. Been seized by fear. Said the wrong thing; spoke in anger. Struggled to find words. All these common experiences, these ordinary workings of the brain, differ from what we call “mental illness” not in substance, but in amplitude and harmonic impact. By that I mean: the brain is the organiest organ—synapses firing together form chords. Press the wrong keys, or too many at once, you get dissonance, cacophony—and deafening, at that. Even silence, in a compromised state, can roar. If you think you’re immune, think again. Be compassionate.

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THE NUMBERS GAME (PART ONE)

 

Summer is the doldrums in community mental health. Outside, heat sits heavy on the day, while inside, the corridors fall silent, as client after client DNAs (Does Not Arrive). Even families who lack means can find better things to do than sit in the stuffy offices of our cinderblock strip-mall building when the sun is out—skipping visits without, often, so much as a how-do-you-do.

Ostensibly, golden rays of sun provide community mental health workers with a golden opportunity to catch up on paperwork. In reality, missed visits mean spending precious time making (and documenting) outreach calls and sending (and documenting) outreach letters, while facing the likely assignment of other clients in order to meet the agency’s billable expectations.

Community mental health agencies are generally positioned as the providers of last resort; at least where I currently live, we are mandated to provide services for any client who presents and meets the state’s criteria of need. That mandate means that we are fronted money by the state and/or insurers (mostly Medicaid) in order to maintain the infrastructure to provide services; but we have to earn that money after the fact by meeting productivity standards, or the agency is required to pay back the difference. (Oversight by the agency’s funders is provided, in part, through random chart audits.)

Let’s say an agency has an expectation of 20 hours of billable (i.e., in-person client) time per therapist per week, plus staff meetings and paperwork. With a 20-hour billable expectation (or 50 percent of the work week, which is on the low end of the spectrum), if a therapist has (for example) 26 clients on her or his caseload, and all 26 arrive for their appointments in a given week, congratulations from supportive team leaders are forthcoming for the success.

If, on the other hand, only 17 of 26 clients make appearances, that’s three short of the minimum required; and if that happens to a therapist more than once or twice in a given timeframe, team leaders are charged with addressing the issue, and more clients are assigned—typically two or three at a time—until billables are consistently met. Since there has never yet been an end to the aforementioned need, there are always clients awaiting assignment to therapists (even if, once assigned, they don’t end up following through). Each new client requires outreach, scheduling—always harder when one’s weekly planner is already at least hypothetically full—and documentation of same.

Add to that the reality that, due to the nature of the agency, each case comes with a truly Sisyphean set of documents: the service plan, the crisis plan, releases of information, attestations of privacy measures and rights and responsibilities; quarterly evaluations, service plan revisions, and eligibility updates; annual reviews (which are like quarterlies x π); and, for every visit, a progress note.

All except the progress notes have to be done for every open case, regardless of a client’s presence or absence. The more clients, the more paperwork. There is even a special set of documentation requirements involved in closing a case, along with extensive dialogue with team leaders prior to taking that step. There is also, in many cases, collateral work to be done, in terms of reaching out to other players: secondary caregivers, DCYF, school personnel, JPPOs—to say nothing of intra-agency collaborations with the staff psychiatrist, case managers, and functional support specialists. Each and every phone call or contact, with or without a resulting conversation, is meant to be formally documented, as evidence of the efforts made on a client’s behalf.

Extra points to any reader who has already thought about the beating heart of the work, not yet mentioned here: whatever else is going on, however great the pressure and stress behind the scenes, when a client does walk through the door, it’s a therapist’s job to be present—to engage or reengage the client in the therapeutic relationship; to meet and respond to the crisis of the hour while holding fast to a greater vision that involves the needs expressed at intake and the goals outlined in the service plan.

We are meant to use evidence-based practices and stay current in the field, without sufficient time (or funds) allotted for that; yet we’re also meant to trust that we already possess the skills needed to work with most clients, whether said client is a disruptive five-year-old, a self-harming twelve-year-old, or a seventeen-year-old with a criminal record. In a given day, we might see all three in succession, with barely time for a bathroom break. We are meant to be familiar with their histories and family systems and have regular contact with any outside providers, as well as reevaluate diagnoses and service plans on a regular basis. We deal in poor attachment, grief, abandonment, trauma—but also in behavioral issues that might in some cases be purely biological, a matter of environmental conditions such as diet or chemical exposures, requiring basic changes to the physical conditions of the client that, due to a limited understanding / appreciation of such factors, simply aren’t made, while therapists are expected to work magic.

The meager pay is a topic for another day. Absentee clients have a way of highlighting the worst aspects of the work, and, through lack of momentum, can drain a therapist’s resources for engagement. Suffice it to say, summer is the time when my thoughts most wander to other possibilities. It is when the work I truly love—supporting and bearing witness to positive change—is at its ebb tide. And, of course, I’m stuck in a stuffy office in a cinderblock strip-mall…

To Be Continued.

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This month marks my third year of keeping this blog! Out of respect for client privacy, names here are always changed or omitted. Text and image copyrights held by me. If you enjoyed this piece, I hope you’ll consider sharing it. To subscribe and receive future posts, please look to the upper right on your computer screen, or scroll to the bottom of the page on your mobile device. Thank you for reading!

MINDFULLER THAN THOU (Part 1)

Almost before I’d even begun this project—which is still very much taking shape, finding form and direction, its raison d’être—I knew I would need to address my own ambivalence toward the language of mindfulness. That the word itself doesn’t appear in the name of this site is no accident, and not only because I thought it too limited for the eclectic approach I hope to take. I have an aversion to trends as such, and to what an acquaintance recently referred to as “spiritual materialism.” If I do yoga now and then, it’s not because I find it “karmalicious.”

It’s all too easy to sound highfaluting, insubstantial, or glib when writing about things like the mind–body connection—when what interests me is substance and an honest and grounded experience of living. I care about integrity, which, like its relative “integer,” means “undivided, whole.” A state in which feeling, thought, word, and deed resonate. I care about these things—but am I an exemplar?

That was a rhetorical question! Just when I think I’m making progress, life has a way of humbling me. This evening’s lesson came in the form of a five-year-old boy who had no interest in my therapeutic gambits on his behalf. (A quick look at the word “gambit” perhaps holds the answer; he may have felt he would be giving me some advantage.) I asked, for example, “If you could be an animal, what kind of animal would you be?” He made no bones about it: “I don’t want to be an animal!” But what do I mean by “progress,” anyway? That’s a fertile subject in itself. If “humble” is related to “humus,” there is rich matter there in the decomposition—the makings of new growth and the thrilling possibility of eventual flowers, honeybees, and fruition.