(UN)PLANNED OBSOLESCENCE

 

“Therapy is not meant to last forever,” I tell my kid clients during our first visit. After inviting them to express their feelings about being brought to counseling, I ask them to think about how they’ll know when the work of therapy is done. What will have changed for them?

In asking this, I hope to empower them and shape our work according to their priorities, not necessarily, or only, those of their caregivers. After all, change requires buy-in. Simultaneously, it is my way of planting a seed for one of therapy’s most important flowerings: the good goodbye.

Everyone can expect to experience loss over the fullness of a lifetime; but childhood, for the clients we see in community mental health, can already be replete with losses both clear and ambiguous. Parents especially seem to disappear, in the county where I currently work—into jail, substance use, other towns and states, other relationships and families, mental illness, accidents, suicide, and even death by homicide.

Such loss is complicated in untold ways, with impacts on identity and self-esteem, attachment, concentration, decision-making, moods, stress, coping style, and the immune system. A positive therapeutic relationship, while not “fixing” all that’s gone before, can be a corrective experience, providing safety, reliability, tolerance and adaptability, support and regard, healthy boundaries, respect, and (crucially) warmth. I would contend that when therapy “works,” that corrective quality is the main reason why.

Bringing closure to all the relating that’s come before, the good goodbye is one that is anticipated, planned for, and—though there’s room for sad feelings as well—celebrated together as an accomplishment. I like to provide client-specific “transitional objects,” small items that can carry forward the memory and meaning of our time together. I’ve given skeleton keys, worry stones, figurines, feathers, memory books, and (so far) one mixed CD, all accompanied by notes or letters of congratulations. One spunky little girl I see has already requested brownies, though the end is not yet in sight; for a teen with a love of savory sweets, I made rosemary shortbread.

Needless perhaps to say, all this preparation is as much for me as for the client. I, too, experience some attachment in my work with clients, to varying degrees, and the good goodbye helps me to find closure for work that has impacted me as well. (In The Body Keeps the Score, Bessel van der Kolk espouses the belief that clients can’t grow and change if they can’t see their impact on their worker; I’m hopeful that my clients can see theirs on me.)

The good goodbye is also a corrective experience for me for other losses, both personal and professional—those goodbyes that never resolve. When denied it—when, as happened late this spring, a favorite client simply drops off the map, our work together feels as open-ended and prone to fraying as an unfinished hem. Though coached by colleagues to trust and let go, it is hard not to comb over my memories of our last visit, for possible clues. Did an errant remark cause pain or offense that the client or caregiver wasn’t comfortable addressing?

It’s impossible to know. Some clients aren’t good about calling under any circumstances, let alone the momentous ones that announce the end. My lost client had made radical progress—was he just doing well enough that he felt he was done? Although I give all credit to him and his mom, did disappearing feel necessary to him, in order to own his gains? Or could it be that a lack of experience with healthy endings might have caused him and/or his mother to dread the emotions of closure? When people protect their emotions, it is often (and often unwittingly, though not always) at others’ expense.

In any case, I send my best wishes to him.

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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. “The Numbers Game” (July 2017) will be continued in a future post, when I have more stamina for the topic. Thank you for reading!

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!

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.

CLEAR-EYED AND COURAGEOUS

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The end of any year, but especially this one, can feel elegiac to many. For me there is no better answer within reach, to the litany of sorrows I could name, than to offer tribute to those who’ve inspired me in the past twelve months—thankfully also a long list. Here are just two.

My first tribute is to a mother of my acquaintance. A little over a dozen years ago, she contrived an ingenious way to save some of her income from her abusive partner, so that she could escape to a women’s shelter with their infant daughter. In the process, she lost a best friend because the friend feared retaliation for any show of support to her. The experience of trauma persisted for a decade, as the man haunted her life, until at last he died of an overdose. Now, never having found time to care for herself, she makes the effort to support her daughter’s ongoing grief over losing her father, whom she had barely known, whose death meant something very different to her.

My second tribute is to a girl of my acquaintance. A daughter in a different family, she recognized her stepfather’s instability long before her mother did and looked up the signs and symptoms of abuse to educate her mother in what was happening to them. She persuaded her mother to divorce the man who would, before they left, harass and molest the girl whose clear vision saw the truth, whose courageous spirit spoke out to make change. This girl-becoming-a-woman now wants to study the brain, maybe work in child development or forensic psychology. She wants to understand things. She wants to make sense of the world.

Certainly there were dozens of men and boys this year who moved and delighted me (including one eight-year-old I know who stated recently that he is now “obsessed with Canada”; the liberal-minded among you can probably guess why). Then there are those (men, women, and algorithms) who miss the mortal glory that surrounds them, profoundly confused by marketed images: made up, airbrushed, photoshopped, contrived, assessed, judged, “had,” bought, and/or sold to the highest or nearest bidder. After the year the world has had, after the year my country has had, after the slurs we’ve all been suffered to hear uttered by persons of influence, I feel inclined to celebrate the real beauty of the women and girls whom I’m proud to have met: their strength and grace of character; their intelligence and the light they carry, kindling within every cell, every smile, every look of comprehension, every gesture of warm and real humanity.

To them and to you, Happy New Year.

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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.

A COUNTERVAILING MAGIC

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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.

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THE TROUBLE WITH UNICORNS

I hadn’t seen Tess in three months, and the first thing she did was take an inventory of my office: “That’s new, that’s new, that’s new, that’s new, that’s new, that’s new, that’s new.” Pointing to sand table, miniatures, artwork on the walls.

I don’t think she missed a thing, except the fluorescent-green pothos cascading splashily from the window ledge. In that way—pointing, naming—she reestablished her relationship with my space and perhaps, by extension, me. Indeed, many things had changed, herself included—she was that much taller, that much smarter, and, happily, seemingly, that much more confident.

Unaltered was my delight in her elfin presence. So earnestly did she press one of her gold-foil chocolate coins upon me, a holiday treat; so sweetly did she show off her new dress, pink and purple, patterned all around with unicorns. I smiled to see it and sang its praises. She seemed happy, and I was glad. And then suddenly I was both there, with her, and far away, in an unidentified garment factory, drearily lit, poorly ventilated, and about the furthest thing from magic.

The trouble with unicorns is not just the trouble with unicorns, but with cartoon pandas and big green trolls and talking sponges in boxer shorts. It’s the trouble with cheap t-shirts emblazoned with “Love,” denim trousers bearing swirls of silver circles—stickers meant, I guess, to look like studs. It’s the trouble with our clothes in general, as well as our toys, our tools, and those devices one might use to read this blog that count as both. Whose labor feeds our restless appetites? What working conditions support the built-in obsolescence of trends? Unicorns as symbols have had a far longer life than most corporate creations; but they, also, have become commodities. Our “magic” is, too often, predicated on misery.

I mostly try to write in tight vignettes because expanding my scope makes me self-conscious, and the more editorial my voice, the more I question its worth in a crowded media world. There are any number of people out there speaking to my values—human rights, fair trade, environmental protections, and restorative justice, to name a few—and I feel that my gift is rather to experience and communicate the depths to be found within moments in time.

At least, that’s what I aspire to do. Thus, the profundity, for me, when Tess created a scene—a vignette of her own—from my miniatures. Six months into foster care, it wasn’t clear whether she’d be placed into a home shared by her siblings; it was even less clear whether she’d be returned to her biological parents one day.

There were babies in Tess’s scene, but no parents visible. I asked where they were, and she said they slept somewhere else. “The babies can live in the doghouse for now,” she said. Her case worker, who’d brought her, intercepted my meaningful look with one of her own. My hopes for Tess intensified—a safe and stable home with brothers and sisters close; parents who get clean and make up for lost time; a secure identity as she grows. But also this: that her new dress wasn’t made by a girl her age. That no one else’s unhappiness fed her little bit of needed joy.

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Names of clients 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. For information on supporting reduced consumerism in kids, check out the Campaign for a Commercial-Free Childhood.

 

 

 

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.

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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.