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!

MY SMALL, GOOD THING

I had an insatiable hunger as a child, which I tried to feed with chapter books, great stacks that I collected on weekly library trips—cradled below my belly and held in place with my chin, as I carried them to the checkout counter.

That hunger is still present, but fiction often feels insubstantial these days, with so little time to spare and so much to accomplish. That shelf of titles on trauma, addiction, blended families, communication, grief, and more—I need what they contain. I need it all, I need it now. Such is the pressing quality of community mental health.

My intimate contact with the stories of traumatized children leaves me with simultaneous and contradictory incentives. One, to write so vividly of the horrors I hear and the pain I witness, that the general reader looks at the world anew: aghast and called to action. Two, to obscure those horrors so as not to titillate prurient minds or inspire troubled imaginations.

Sitting with memories of trauma is usually manageable; harder by far is to know that a trauma is ongoing—unfolding right before me in my office at times, in the words of caregivers who evidence no care to give, likely having received too little when they themselves were small. Harder is listening to parents, grandparents, and guardians who are overwhelmed and relentlessly negative, who fill the ears and hearts of their charges with every kind of blame and shame, each and every possible iteration of No. Needing to be diplomatic for the umpteenth time, when that is the last thing I feel; turning down the heat lest I, too, boil over.

So it is that I recommend Raymond Carver’s story, “A Small, Good Thing,” a masterful sketch of anguish in the ordinary world, and the humble ways we can assuage it. I reread it not long ago and carry that title within me, a phrase that describes the bird feeder on my window. How it took the birds two weeks to find it, but the first I saw was the male house finch, ardently red from crown to breast and finely patterned white and brown beneath. How the female house finch brings their juveniles to feed them beak to beak, while the punk-rock tufted titmouse busies himself with the sunflower seed.

Whatever else the day brings, there is that.

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The Raymond Carver story mentioned above appears in his great collection Cathedral, as well as numerous anthologies. 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, please 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!

DANDELIONS

 

 

Near a local school, 12:30PM on this sunny Sunday, three little girls ran past me as I walked home from town. Two had hands full of dandelions; the third ran behind, calling to them—friends or sisters—to wait. It sounded like she was saying, “I don’t have any more!” Was she feeling left out? I remember that sensation all too well.

My next steps landed me in front of a perfect long-stemmed dandelion, recently plucked and then dropped on the sidewalk, so I picked it up and turned around, exclaiming, “Here’s one!” The girl stopped and did an about-face. “Here’s one that fell,” I elaborated. “Perhaps you’d like to have it.”

I held it out, and she approached. I extended my arm so she wouldn’t have to come too close to me; she reciprocated by reaching from a distance as well. She didn’t seem fearful, just wise and well-taught about strangers. Perhaps also surprised by my unexpected offer. Dandelion in hand, she turned and ran again, catching up.

Spending most of one’s time with traumatized children can make it, at times, almost startling to encounter other children in the world, children whose close and consistent care is evident. So it was for me this morning: a single glance took in the girls’ healthy complexions, tidy attire, and air of confidence.

I mused on the matter as I resumed my path. I had flashes of thought about the adverse childhood experiences (ACEs) of the children I’ve come to know in my work: neglect, abandonment, victimization, exposure to violence and substances; and flashes of the little signs of growth and change that mean so much to me, like a moment of relaxation in a face that’s usually tense, a self-protective girl I know whose laughter sometimes breaks through her reserve with as much light as those fistfuls of sunshine I’d just seen.

Then suddenly there was another dandelion before me on the sidewalk—and then another, and then another, and then another, stretching from my feet toward the point near the library where, one June night, I once had a memorable second first kiss. The girls weren’t losing their flowers; they were dropping them purposefully! What grand design were they enacting, with weeds that aren’t weeds? Leaving a trail of happiness behind them, abundant as the marigolds in Monsoon Wedding.

Picking one more up, I held it to my nose and breathed it in. How had I never realized how fragrant dandelions can be? I walked home amid lilacs, flowering trees, tulips blown open, massive bumble bees. I wished the good luck of this world on everyone.

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Out of respect for client privacy, names are always changed or omitted. Text and image copyrights held by me. If you enjoyed this piece, please 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.

ONCE UPON A TIME (PART FOUR)

 

What follows is (the 4th and final part of) a story about stories and the wisdom of a six-year-old girl. (Click to catch up on Parts 1, 2, and 3.) I chose to tell this story in parts not just to make the length more manageable, but also because it held several climactic points for me. There are two remaining.

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The meeting with Sarah, her teacher, and my supervisor fell—as mentioned in the prior installment—quite near the end of my internship. Daily I busied myself, preparing for “good goodbyes,” making memory books and hosting last lunches with kids. With only two days a week there, I wasn’t present for the sharing of Sarah’s stories with her class, but Sarah’s teacher said the other children were quiet and attentive as she read aloud the chapters that Sarah had written with me. (I can picture Sarah among them, listening with her whole being.) When it was over, according to Sarah’s teacher, various classmates shared their reactions, all of them kind. One child asked the gorgeously mature and sensitive question, “Do you really feel lonely?”

“Sometimes,” Sarah said.

Sarah had claimed her loneliness again—and this time publicly, among peers. How many of us are able to do that? How many of us “gwownups” are so undaunted, to name what we feel and admit to others what we crave? How often, moreover, are we heard? Properly acknowledged, problems have a tendency to shrink. In addition to admiration for Sarah, her class, and her teacher, I felt hope: she had said “Sometimes,” rather than “Yes.” Could it be that loneliness was gliding away from a total eclipse of her heart?

I returned to the school a week or two after my last day, to give a short presentation at a faculty meeting and turn in my keys. Unbeknownst to me, my supervisor had made a memory book for me, with messages from the kids that I had worked with. I wish I could share the photo, but Sarah is in it, standing before a whiteboard portrait of us, side by side and smiling wide, arms outstretched, fingertips almost touching. It looks like we’re embracing the world. Her message beneath the photo concludes this way: “I had fun visiting you with my friends at school.”

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A gentleman in New Zealand, with whom I’m loosely acquainted via online forums such as this, told a story once about his granddaughter, who had been taught baby sign language from birth:

“My daughter would sign every time she spoke to her daughter. My granddaughter was able to communicate quite effectively well before she could be expected to start talking. I can remember her telling me about what for her was a very traumatic experience when she was around 18 months old. She had seen their cat catch and injure a bird. The bird had been rescued, but it died shortly after. She signed the entire story, much of which I could understand. Some needed to be translated by her mother as I wasn’t fully fluent in their “baby sign,” but it was so heartbreaking to watch her little face as [she] told how the bird had died and they carefully buried it in the garden.”

We are made of stories and need to tell them. Children often need (and always deserve) our support in this. If we say, “Once upon a time,” what enlightening tales might follow?

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Out of respect for client privacy, names are always changed. Barry’s sign language story can be found in the comments of this Musings of an Aspie post. Other text and image copyrights herein held by me. If you enjoyed this piece, please 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.

ONCE UPON A TIME (PART THREE)

 

What follows is (Part 3 of) a story about stories and the wisdom of a six-year-old girl, written back when I was working my first of two internships for my master’s degree. (Click to catch up on Parts 1 and 2.)

When I read back the last line of their story, Sarah and Addie looked so delighted that I thought they might start jumping up and down. I felt, myself, like doing so. At the beginning of the lunch experiment, I’d had a dream in which I saw solitary Sarah playing outside with a friend. Could that dream finally be near to coming true?

“Read it again!” said the girls. So I did. Then, wanting to fortify their newfound camaraderie, I asked if they might like to have their story read aloud to the rest of their class.

Yes, said Sarah—“and the other chapters.”

She seemed determined to share her experience of kindergarten isolation, and it dawned on me that there might be a kind of “greater vision” to her fixation—certainly greater than I alone could perceive—so as a next step, with Sarah’s permission, I invited her teacher and my supervisor to join us for a private sharing of both stories.

Picture a wide-eyed little girl, seated among three adult women: I felt we were surrounding her with care, and I felt that she felt it, too. For the first time since I’d met her, it was as if I could see the whole child—not at a remove, no feint of silliness, but present, visible, and wanting love.

I was again the reader, as Sarah watched her audience of listeners: the vivacious school social worker who greeted her in the hallway every morning, and the kind teacher so clearly valuing the rare chance to give Sarah her undivided attention.

When I reached the end of the last chapter, there was silence. I’d known silence in dyads, but I think that was the first time I’d experienced a therapeutic silence within a small-group setting, and I didn’t recognize and respect it for what it was. Instead, I felt self-conscious, like the hostess of a party that had ground to a halt; I quickly offered to read the other, shorter story.

Thankfully, Sarah’s teacher and my supervisor asked if they could first express what they were feeling. They felt sad and worried, they said. Like me, they wanted to know what they could do to help. Sarah asked, again, if the story could be read to her class.

I want to pause here, creating the smallest delay in your reading, slowing down time the way it slowed for me, to register my astonishment at what my six-year-old client then attested with utter clarity.

“People need to know,” she said.

Sarah’s teacher agreed immediately, and I felt tremendous relief. What was sought would be provided, in a context that would make sense. Stories are expected in a kindergarten classroom; indeed, they possess a ritual importance. Sarah’s teacher, with decades of experience, would know what to do.

That was my cue to move on to the light-hearted tale of mischief, which everyone seemed to enjoy, with broad smiles all around. Then, because I would be leaving my internship soon, we agreed together on a plan for my supervisor to take over the act of transcription: lunches with classmates would continue, and the story project would, too. I would have one more turn with it, meeting a serious-minded Brian the Bear before regretfully ceding the magical binder and clearing out the stash of penciled drafts in my desk.

To Be Continued.

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Out of respect for client privacy, names are always changed. Text and image copyrights held by me. If you enjoyed this piece, please 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.

ONCE UPON A TIME (PART TWO)

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What follows is (Part 2 of) a story about stories and the wisdom of a six-year-old girl, written back when I was working my first of two internships for my master’s degree. To catch up on Part 1, click here.

The day that “Sarah the Cat” laid claim to her human loneliness, I formulated a plan: she could invite one classmate each week to have lunch with us in the guidance room, which for kindergarteners holds no stigma and instead represents a treat. Sarah might gain some status among her peers, and lunch might naturally segue into companionship at recess.

The boy she chose for her first guest was shy and sweet but not the best bet for an aide-de-camp in the project, accompanied by a paraprofessional in case he felt overwhelmed. Sarah’s teacher suggested the next invitee, a girl whose confidence proved unhelpful, with a domineering quality that crowded out the native empathy she might have possessed. Our third guest seemed like a Goldilocks choice—generous, polite, just right!—but nothing came of it.

Not socially gifted myself, in vain I struggled to make small talk that would help the kids learn about each other; like an awkward matchmaker, I even asked about favorite playground games. Sarah gave me a look at one point, and I wondered if I was being too obvious. Despite my efforts on her behalf, there was no sign of a shift—she still floated through her days disconnected.

Meanwhile, Sarah and I kept our Monday morning meetings. The day before our fourth Tuesday lunch, I had brought in all her chapters, typed from my longhand transcriptions and organized in their own slim binder. My internship at the school would be ending relatively soon, and creating books with and for kids was part of the process of saying goodbye. The chapters looked impressively official, dressed up thus. Sarah asked that I reread them to her; she seemed to enjoy hearing even the hardest parts.

The next day I walked down to rendezvous with Sarah and Addie, aka Guest Number 4. We gathered lunch trays, straws, utensils, and assorted condiments, and climbed the stairs, the kindergarteners’ knees bobbing high to accommodate the rise of each step, their trays held carefully aloft. So far, so familiar—but Sarah cast me into the unknown the moment we entered the office. “Could you please get my book and wead it?” she asked, the lost r tugging my heartstrings, while Addie preceded us to the table. “You want me to read it—out loud?” I clarified, hoping I’d misunderstood. “Yes, please,” she said.

What was I going to do? I looked over at Addie, concentrating on her carton of milk, plucking her straw from its cellophane wrapper. How could I subject that curly-headed naïf so unexpectedly to a tale of unremitting loneliness? Over pizza sticks and a small heap of syrupy fruit, no less? I was not thinking fast enough and grasped at a fib. “I’m not sure I have it with me,” I said, pretending to search my backpack. “No, I’m sorry, I don’t have it.” I felt conflicted about the now-outright lie—but there it was.

She persisted, asking me in that case to say it from memory. Again, I demurred. Then came the flash, the genuine inspiration. “What if we write a new chapter today? To a different story?” One thought led to the next. “Maybe Addie can help—if she wants.”

My enthusiasm for the idea was initially unshared. “Okay,” Sarah said. “But can you bring it next time? It’s important.” It’s important. “Alright,” I said. I’d bought myself a little time, but I knew I couldn’t ignore those words. I seated myself across from the girls, pencil at the ready. First we established our new character. Who would Addie like to be? She chose readily.

“Once upon a time, Sarah the Cat and Addie the Easter Bunny…” It was lovely to see both girls giggle at that. Sarah led off from there, but Addie caught right up. As they built their story detail by detail, they looked at each other for affirmation, grinning as they dreamed up mischief.

The plot unfolded as follows: They were at a picnic but wandered away from their blanket, landing them in hot water with their parents, who followed their trail, found them, and condemned them to their rooms with no dinner. Confining myself to prompts up till then, I volunteered a last line: “What a terrible way for a picnic to end!” The girls, together, approved.

To Be Continued.

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Out of respect for client privacy, names are always changed. Text and image copyrights held by me. If you enjoyed this piece, please 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.

THERAPY IMPROV!

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Given the current historical moment, I find myself in need of humor born from innocence, not facing its own death on the gallows.* Realizing that today’s post was meant to be Part 2 of the poignant story begun last month, I nonetheless hope you’ll enjoy this station break from Doomsday programming, reflected in the arc of the post.

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It had been a Day. I’d spent it with a young man who’d punched a wall before our morning appointment, who sat silent and hurting before me for an hour, his knuckles raw; then with his mother, who fought the urge to beat the son who had been beaten as a child by her ex-husband and abuser. Then with a formerly neglected little girl almost paralyzed by the fear that her advocate and protector might be taken from her, any minute, by illness or a relative’s intervention.

I’d spent it with a teen whose biological father had abandoned her, who had made sexual allegations against her mother’s long-time live-in partner, then retracted them when faced with the possibility of a broken home, then attested to them again after investigations had been closed. I’d spent it debriefing with my supervisor about how to handle the information and the necessary DCYF call, as well as seeking advice on another volatile case, of a bitter custodial dispute, with the vilest he-said, she-said I’ve yet encountered.

Before, between, and after all that, I made calls and filed notes on those calls; closed two cases; worked to catch up on paperwork that by Wednesday had buried me in an avalanche, after I’d started the week with a clear desk and a clean slate; and participated in a group interview of a clearly gifted therapist—knowing, as I asked questions and made welcome, how low our team morale was, how hard the work of community mental health truly is, and how poorly appreciated, to say nothing of compensated, by our administration we all felt.

Then it was five o’clock, my last appointment of the day: a new-to-me client inherited from a recently defected colleague’s caseload, a small boy with a startling vocabulary and a lisp, brought in by his current guardian. “Look, it’s my stress ball!” he said, showing me a spongy tennis-ball-sized approximation of our planet. I asked if I could hold it. I gave it a squeeze and turned it around. “Oh, look!” I said, locating the blobby outlines of our country; I pointed to our misshapen corner of it. “There we are!”

“We’re not there!” he said. “Yes, we are,” I said, pointing again— “See? You’re wearing a red shirt and tennis shoes.” He drifted away from me and stood looking out the window. “What are you doing?” his guardian asked, bemused. He turned back to look at me in challenge: “I don’t see your finger!”

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Out of respect for client privacy, names are always changed. Text and image copyrights held by me. If you enjoyed this piece, please 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. * “Gallows humor,” for non-native English speakers, is humor conjured when prospects are grim.