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!