JANUARY 20, 2018 / MARCH

 

 

I overheard this in the crowd today:

Mother: Do you want me to put you on my shoulders?

Daughter: You can’t pick me up!

Mother: Yes, I can.

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Please excuse the brief departure from my once-a-month posting routine! Please also excuse the unedited collage; I’m still learning WordPress. Text and image copyrights held by me. 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), now long delayed, will be continued in a future post, when I have more stamina for the topic. Represent!

 

META ON METTA

 

The end of any year brings seemingly innumerable invitations to make financial pledges. This is not one such! It is a contemplation, rather, on the merits of taking the whole process of New Year’s resolutions one step further, by creating or adopting a meaningful philosophical pledge, for the coming year and beyond—a pledge that, like metta meditation, moves you to consider your own life and the life of the world through the same lens—then post it somewhere prominent where you won’t fail to see it. A dashboard could work, for those idle moments in traffic. The back of a smart-phone case, as a tactile reminder on an abstract medium. A few valuable inches on your fridge.

I do my damnedest, in this writing, to maintain a positive approach to the subject at hand; I could opine all day long, but the virtual world is full of tirades already. I also try to be simple and straightforward; there’s an overabundance of glib commentary. With the conscious effort that my approach can require, I help reorient myself toward my own higher ideals—of which I not infrequently lose sight in my day-to-day interactions. I mostly write about my therapeutic work; but I’m no plaster saint, to use an old expression. As a child, I was asked to suppress my anger, and it’s still coming out now—mostly in the form of outrage over this and that aspect of culture, all the grievous injustices of which I’m aware, but also things that hit close to home and close to the bone, failures of friendship and emotional betrayals.

So: New Year’s resolutions are all well and good—my default is “Write more; swear less”—but I also need something bigger, deeper, stronger. Something to help me face the daily challenge of living, above and beyond a singular achievement, however important. My very first client, at my first internship, helped me to realize this. Whereas I had grown up in a broken-down neighborhood in a broken-down city, she lived a semi-rural life and loved her chickens with every fiber of her beautiful being—knew their personalities and followed events in the pecking order like a telenovela. Together we worked on validating her negative feelings, so that instead of being suppressed, they might transform themselves and empower her.

Through her, I came to be aware of the 4-H pledge: “I pledge my head to clearer thinking, my heart to greater loyalty, my hands to larger service, and my health to better living, for my club, my community, my country, and my world.” I saw her living out those values in continuing to love those who had hurt her, despite looking with clear eyes at their flaws, and rising above the chaos she’d known at home. The first four assertions have spoken to me ever since, like a nondenominational statement of grace. (I have mixed feelings about that string of possessive mys, and those feelings amplify as the picture gets bigger. Whose world? Our world.) An even simpler distillation of values, which for me is supremely grounding, is posted above my desk at work, a reminder to me and my clients: Be curious.

In 2018 and thereafter, I hope that ecosystems will be protected and valued as sacred, and that workers will be fairly paid and treated. I hope the humble honeybee, with its staggering commitment to fructifying the earth, will survive colony collapse. I hope that the rights of women, and various vulnerable populations, will be recognized and upheld. I hope that buzz words like “slow food” and “slow fashion” will build up to full-on movements, and that the doomed cultures of Agribusiness and Big Pharma will fall. Food doesn’t come from factories, and answers don’t come in pills. I hope that we collectively will have the resilience to develop the patience to labor on toward real answers—many of which can be found in traditions whose caretakers are indigenous peoples. And, of course, I hope children grow up feeling safe, loved, and respected. So many visions and wishes for our planet. I’ll be doing my part as best I can. I share these thoughts today, in this quiet corner of the internet—deliberately free from the commercial intrusions of ads—as an act of loving-kindness: I wish good things for me, and I wish them for you.

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Out of respect for client privacy, names here are always changed or omitted, and details may be altered in fact while relevant in spirit. 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), now long delayed, will be continued in a future post, when I have more stamina for the topic. Thank you for reading!

 

INVISIBLE INK

 

We were walking together alongside the building when he veered away from me to climb the perimeter of an unused loading dock. He had done that before, on another walk, and appeared cheerfully confident of my discomfort as he placed one foot before the other on the concrete edge, tightrope-style. Dismissing my worries about his safety, he compared me to his granny, who was his guardian and whom he described as “your standard, everyday grandmother.”

Well, I didn’t correct him on that point; for a kid with his background, being able to take a caregiver for granted is a hard-won luxury. However, I can tell you, she was anything but ordinary. For one thing, she was actually his great-grandmother; her early life unfolded against a backdrop of WWII, yet she was still working full-time and ferrying kids to after-school activities when I started seeing them.

Before she obtained custody, she drove to Jason’s house each day—never knowing what she would find—to take him to school. Without her, he wouldn’t have gotten there, neglected among adults whose lives were given over to pills and needles. Now she was raising him. On a rainy afternoon, as she and I were chatting, I glanced down and noticed matching holes, big as silver dollars, worn into the top of each shoe; she laughed as she admitted she was too busy to try on new ones.

It’s thanks in no small part to her, I’m thinking, that Jason was able to hold his own in the world. His bravado on the loading dock notwithstanding, he had at least one quotidian fear that could send him into a panic. Perhaps that’s why it was tempting for him to show off a bit of fearlessness with me—it was probably empowering for him to scare me in that little way.

Someone had given him a pen that wrote in invisible ink. He brought it to show me once, and was writing secret hieroglyphs on the waiting room walls when I walked out to greet him. They would only be visible in purple light, he said. I think about that, and I think about his history, which he wasn’t inclined or equipped to discuss. Hopefully that exploration would happen one day. So much of our lives are written in invisible ink; it takes the right kind of light, shone in the right places, to reveal what is hidden in plain sight. At its best, counseling can shine a soft violet beam—which is, in fact, a careful reflection of a client’s own light.

Late November is meant, in my part of the world, to be a season of gratitude. This year I feel grateful on Jason’s behalf for the care I saw him receive—for the memory of his great-grandmother’s hand ruffling his red hair as she said, when I asked how his week had been, “He’s a good boy.” And I’m grateful for the invisible heart he drew on my hand. Despite innumerable washings since, it’s still there.

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Out of respect for client privacy, names here are always changed or omitted, and details may be altered in fact while relevant in spirit. 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), now long delayed, will be continued in a future post, when I have more stamina for the topic. Thank you for reading!

(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.