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.

+

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.

+

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!

ROSA RUGOSA

 

Rosa Rugosa

 

There seems to be a particularly deep peace in the early morning after a summer holiday night. Twenty minutes of fireworks, costing goodness knows how much, the sparkles beguiling but the clouds of colored smoke reminding me, unfortunately, of bomb blasts in distant countries—I was glad to wake to birdsong at dawn.

Walking, I came upon some metaphorical evidence of the humming life within all seemingly still things, charged like electrons, active as the heart while drowsing alongside one’s beloved: the determined industry of bees.

Working with families in a community mental health agency, one of the greatest obstacles to overcome is absolutism, especially as it usually skews negative. Whether or not people begin by believing the condemning things they say, in saying them, they’re helping to enact them. You hurt me? You’re a menace. You betrayed me? You’re a cheat. Feelings about behaviors blow up into characterizations; to surmount them is a Sisyphean task. And I’m not talking about couples counseling—parents express these feelings toward their children! Their learning, growing offspring who are, primarily, shaped by their home environments and the nurturing they get or don’t get!

A great part of a therapist’s work, in such situations, is to solicit alternatives, shades of gray, moments of success—which typically involves demonstrating patience, modeling genuine curiosity, making judicious observations, and celebrating the tiniest of shifts. As a historically catastrophic thinker, I’m often moved and inspired by this process. If in February, Angelique and her mother were fighting bitterly, and they’re still fighting in March, it’s nonetheless notable if their body language has changed. They sat apart, now they’re sitting closer; their legs were crossed away from each other; now they’re almost touching. There’s hope in that.

It was a big shrubby rose bush that caught my attention today. Almost all the flowers were long gone, revealing green rose hips, and the few remaining blossoms were tattered and shattered. Nonetheless, for the solid hour encompassing my walk—I passed it twice—bumble bees were diving in and out, clearly determined to harvest all the pollen they could, their padded back legs proof of their reward.

Whilesoever there’s a blossom, however damaged, there’s work to be done—a treasure hunt that makes possible all the blossoms to come.

+

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 click the “Follow” button, accompanied by a plus-sign, in the lower right corner of your computer screen. Thank you for reading.

PRIDE

Ectoplasmic rainbow

“Did you tell your counselor what you said to me in the car?”

“No,” said Mercedes, with a smirk followed by a giggle.

“You should tell her!” her mom exclaimed.

“No, you tell her!”

“You don’t want to tell her?”

“No, I want to hear you.”

+

Mercedes had come to services as a high-strung nine-year-old with separation anxiety. After eight months’ worth of escapades designed to develop her confidence, she was ten years old and seemed pretty near ready to command the universe. (Our fast-slow games and yarn telegraph in the hallway provided unintended ancillary outcomes in the smiles of amused and bemused colleagues passing by.)

As her parents described it to me, they had felt hostage to their daughter’s need for constant reassurance. She’d required accompaniment to her classroom each morning and a detailed outline in her planner regarding who would pick her up after school, when, and how. Her mother included a cheering note in Mercedes’s packed lunch each day. Mercedes couldn’t be left home alone for even a handful of minutes. Breaches of protocol led to tearful fits.

All that changed, and more. I’ll try to write another time about our work, much of it disguised as silliness. Notable here is her parents’ support of their daughter’s therapeutic homework, and Mercedes’s willingness to engage in same. More than anything I did, that made the difference. Deep breathing practice was added to her bedtime routine, along with a recitation of three things that made her happy. Three things every night without fail, that was the only rule—they could repeat or vary endlessly, and be substantial, like visiting grandparents, or lighter, like an extra-yummy breakfast.

Notable also, on the part of her parents, was their extraordinary ability to identify and celebrate positive change. Too many parents with whom I’ve worked have goal posts that constantly recede, such that nothing their kids do is ever enough. As an adult, I find that approach profoundly disheartening; how much worse must their kids feel? When Mercedes volunteered to take half the grocery list and split off from her dad in the store to find things—one of the early positive signs—the confidence and independence she expressed got the recognition they deserved. Blessings upon you, parents of Mercedes!

My inspiration to write about this family this particular week, however, came from another form of recognition, during our last visit. First, I presented Mercedes with the book of skills and stories she had created bit by bit. In the back, there was a letter from me. When we met, she’d chosen a skeleton key from a set of images, as the one representing something about what had brought her to counseling. “I hope when I’m done, I’ll have the key to my worries,” she’d said. Ceremonially, I presented her with an actual skeleton key, which I’d chosen the summer before from a tool chest at a flea market, with an inkling that it would serve a purpose someday.

In reviewing her accomplishments to date, Mercedes’s mom mentioned forgetting a note in the usual packed lunch; it wasn’t, to her surprise, the end of the world. A ruined batch of birthday cupcakes had Mercedes reassuring her mom, “It’s not worth getting upset about.” She could enter school by herself, and take the bus in the afternoon, looking after herself at home for an hour or two. She even seemed to enjoy her time alone. But the most striking detail shared that day, for me, had to do with her seemingly growing assertion of selfhood.

So what had happened in the car? Apparently her mom had made some reference to Mercedes growing up, how one day she’d be bringing boys home and taking her dad to a whole new level of stress. And apparently Mercedes had rejoined from the back seat, “What if I like girls?”

Mercedes giggled again, hearing me hear it.

“And what did I say?” asked her mom. Her lovely, fond, invested, teasing, caring, and committed mom, who had gamely partaken of all our adventures, including holding an end of red yarn while her daughter backed away unrolling the ball of it. “Are you still there?” I encouraged her to ask her mom every step or so, tugging the telegraph line, while her mother answered, “Still here,” tugging in reply. Eventually Mercedes rounded a corner and kept up an unspoken communication—out of sight, on her own, but still connected. We talked afterward about the metaphor of that—how our invisible connection to those we love might look, if we could see it, like that red yarn. Securely held while giving and receiving.

About her daughter possibly being gay, her mother turned the beam of her smile from Mercedes to me and back: “I told her that would be just fine with us.”

+

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 click the “Follow” button, accompanied by a plus-sign, in the lower right corner of your computer screen. Thank you for reading. I was greatly inspired, in my work with this client, by Playful Parenting and The Opposite of Worry, by Lawrence J. Cohen. My deepest condolences to all who have lost their loved ones to violent crimes, including hate crimes.

PAPIER-MACHE, IN TWO PARTS

This story starts at my inner-city parochial school, where supplies were so sparse that at one point we were sharing a single box of construction paper amongst grades Pre-K through 8. I can still recall my pride upon being chosen by Mrs. Z to leave my 1st grade classroom and walk down the grand black-tiled hall to request the box from another teacher—head held high in my state of importance, I fervently hoped to be witnessed.

What my school lacked in resources, it made up for amply in spirit, thanks in no small part to the cultural influence of the Spanish-speaking families in our parish. The Sisters who ran things, all Caucasian, embraced those families and honored Our Lady of Guadalupe. Looking back from this distance, in a culturally hostile hour, I admire the welcome offered by administrators who would have first come to know the neighborhood when it was all Polish, before the sugar skulls of the Day of the Dead bedecked the shelves of the shabby nearby bakery. A local woman was brought in to teach us Spanish hymns. Most thrilling were the piñatas.

Preparing for an all-school festival, each class worked together at long tables in the basement, soaking strips of newspaper in gummy flour paste and laying them bubbled and buckling over balloons. Smoothed, dried, painted, and strung up in the school gym—a magical transformation—they bobbed as each member of each class, taking turns, got to leverage one blind-folded swing, until a spill of candy hit the floor.

*

The story continues with Cybil, 14, who was hospitalized several times for suicidality before she came to the agency seeking services. I liked her instantly, which made it relatively easy to build the rapport that is crucial with any client, but perhaps especially with teens; she had a mordant wit and a sensitive heart, both of which provided points of connection. One evening early on she interrupted herself and looked up from her mandala, colored pencil poised, and asked, tremulously, “You know I’m not doing this for attention, right?” It was already clear she had heard that accusation many times before.

Thanks to Cybil’s engagement in session and commitment to her therapeutic homework, within several months, she had stopped cutting—then, later, purging. Much of our work, though, still lay ahead. Ahead, and below.

In ways beyond my ken, I’m sure the speculated hard inner core and molten outer core of the Earth make all life possible; but the hard inner core of pain and molten outer core of anger, beneath a crust of scars and mantle of “behaviors,” almost cost Cybil hers. She told me that it wasn’t so much that she didn’t want to talk about things, as that she didn’t know where to start.

Reception at the agency had a vestigial practice of printing visit slips, despite the transition to computerized record-keeping. Several clients were aware, when they turned them over to me, that I put them in a file marked “To Shred.” As she and her mother prepared to leave one night, Cybil handed me hers: “Oh, here, do you want this for your file?”

“Sure,” I replied, “unless you’d like to keep it for yours.”

“I’ll be able to wallpaper my room with them pretty soon.”

Her mother and I exchanged quick looks; she seemed to hear what I did. All that stigma, writ large in Cybil’s life. “Why wallpaper?” asked her mother. “How about papier-mâché?”

“Yes!”—I seized on that. “What about a piñata?” Cybil liked candy, and she deserved a celebration. Transformation for transformation. “You could fill it with sweet things and baubles!” I imagined—I hope we three collectively imagined—a jaunty silk scarf tied above her fine nose and wide smile.

“I like that,” she said. Her mom agreed.

+

Out of respect for client privacy, names are always changed. If you enjoyed this piece, please consider sharing it. To subscribe and receive future posts, please click the “Follow” button, accompanied by a plus-sign, in the lower right corner of your computer screen.

 

 

A COUNTERVAILING MAGIC

DSC02315

Last evening I was running some errands in town when the owner of a tiny used-and-antiquarian bookstore, bald in the style of a sea captain, flagged me down: he had a couple somethings I’d asked for months prior. So I went in, and settled into a narrow armchair, losing track of time until I realized that his open sign hadn’t been up, and I was likely keeping him from his tea.

He waved off my apology; he was staying late, as it happened. A young man would be bringing his girlfriend by, to guide her toward a certain book with a carved-out center containing—yes—a ring. Once said young man had proposed, the owner would clear a space for a small, well-appointed table, and a local restaurant would provide a catered meal. (I didn’t ask, but imagined a lone violinist there as well.)

Hearing that, surrounded by a warren of shelves all but obscuring the ancient blue wallpaper, with a peach-faced lovebird singing in the other room— “Alas, in a cage,” said the bookseller—was an instance of countervailing magic, the current that runs against the ills of the world. Such encounters—magic is always an encounter in some form or another—restore me to joy.

There is a great deal of pain involved in working with children. My first client, as an intern, was a little girl whose mother punched her in the nose and took an ax to her father’s car; she couldn’t concentrate in class and wept for the loss of an animal she’d loved, plus everything else, tears that shook her frame. We did a sensory inventory one day, and the wind spoke to her and told her to find her own safe place in the landscape at home; she let a pond remind her of peace, and the sun shining through a leafy trellis bring her hope. Magic: her dear, intelligent face, as we meditated at a picnic table, beneath the tall tall trees and a vibrant sky. May it carry her forth.

+

If you enjoyed this piece, please consider sharing it. To subscribe and receive future posts, please click the “Follow” button, accompanied by a plus-sign, in the lower right corner of your computer screen.

 

A NEW MYTHOLOGY

 

Luz's winter coat

 

If you were holding my resume in your hands, you might knit your brows in perplexity at my apparent vocational 180, from the literary arts to clinical social work. I had to justify that even for an unpaid internship. But the fields aren’t really so different: both involve stories, and the language we use to tell them.

From creation myths (the Raven who steals the light; the “Vows” section in the New York Times) to a well-written obit, I’m easily moved when a narrative thread drops a plumb line through a person’s or a culture’s history.

Stories aren’t without their hazards, though. In a single day, we can tell ourselves dozens, often contradictory, tracking the vicissitudes of feelings and fortune. Yet we tend to privilege certain of those narratives above others, sometimes with disastrous results. Many suicides, for example, could be seen as failure narratives: My life will never get better than this.

The interaction between biology and story is too much for me to take on here and now, but suffice it to say our biological states predispose us in narrative directions.

In relationships, our dominant narratives tend to map out the roles that we play. Many kids who come to counseling have been marked within their families as The Problem, so long and so exclusively that they seem to stand no chance of being seen as anything else. While parents may legitimately worry about safety and trust, kids equally legitimately don’t want to have to drag past mistakes alongside them.

The work of counseling, then, is to open up the story, let it breathe, and help it gradually evolve. I believe that we all deserve to play more than one role in our lives, especially to be both nurturer and nurtured. In some settings—at work, for example, or among acquaintances—relatively simple and fixed roles may make sense. But too many of us in our private lives conduct our own personal Stanford Prison Experiment, becoming the (unhappy) parts we play.

*

My still-much-missed client Luz was, at age 8, a great storyteller. “Once upon a time…” was all I’d have to say, then I’d take dictation. This started in our first visit, when I was fired up to try a narrative technique I’d read about. Through a Spanish interpreter, I asked Luz and her mother to tell me a story with animals playing their parts. (Luz’s mother began to cry relating the story of a daddy wolf who got sick and couldn’t provide for his wife and their children. Fortunately, that story ended well.)

Shy and brief at first, like Luz herself, the stories over time became more complex, until near the end of our time Luz told me this one:

Once upon a time, there were two turtles, and one turtle was Mama and a girl turtle named Luz. Luz, she always played with her dolls. One day, Mama Turtle said, “I’m going to the store—you stay inside and don’t open the window or door!” Luz Turtle was not listening; she was playing with her dolls. Then someone knocked on the door. “Ding-dong!” It was a hawk! The turtle, Luz, she opened the door and said, “What do you want, Hawk?” The hawk said, “I’m here to ask for a turtle to eat.” Luz ran upstairs and locked the door. The hawk was angry and flew up and then down the chimney into the room. Then he said, “Open the door, or I’m going to eat you!” and the turtle said, “Not by my shell!” The hawk knocked on the door, and the turtle escaped from the room through the window. “Where is that turtle?!” said the hawk. The turtle ran and found a fox—a police fox! The police fox said, “What’s wrong? Why are you running?” Luz Turtle said, “A hawk is chasing me! He wants to eat me!” The police fox asked, “Where is he?” Luz Turtle said, “In my house, in my room!” The police fox went to the house to talk to the hawk. “Oh, Hawk, go away—find another turtle to eat!” The hawk said, “What are you going to do about it?!” “I’ll put you in jail if you eat this little turtle!” said the fox. “I’ll get you next time,” the hawk said to Luz. After that, Mama Turtle came home. “What’s going on? Why is everything open? I told you to leave the door shut!” Luz Turtle said, “I’m sorry, Mama. I wasn’t listening.” Then she told the story about the hawk.

THE END

Luz had come to counseling with generalized anxiety, much of it related to border-crossing, separations, and the INS. She couldn’t bear to see her parents drive away, even on short errands. By the time of this story, however, several months into counseling, Luz seemed to have conquered her anxiety. With decreasing worry and increasing confidence, she began to act out other roles of childhood—kicking up a fuss about going to bed, for example, when she wanted to watch TV with her older siblings. (Luz’s mom seemed to take this in stride, fondly stroking her daughter’s cheek. Would that all parents could retain such positive regard when discussing tantrums.)

I see in the story of the turtle in peril a meeting and mingling of two major themes, fear and disobedience, with an experience of protection and survival—however tentative that survival might seem, from the hawk’s parting shot. Privately, because I love foxes, I delighted in Luz Turtle’s unlikely hero. (Had I told her they were my favorites? I couldn’t remember!) Openly, Luz delighted in her own wit, her “Not by my shell!” a turtle’s version of “Not by the hair on my chinny-chin-chin!”

Luz, walking with me down the hall in her winter boots and pompom hat. From her, I learned a new genre: the preservation myth.

 

*Real names are never used here, to protect client privacy. Luz’s story shared with permission.