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!

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.

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.

ONCE UPON A TIME (PART ONE)

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What follows is (Part 1 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.

I’d been spending time with Sarah every week for several months because, although smart as all get out, she was failing to thrive in the classroom. Her teacher reported that she seemed to float in a fog.

We knew her parents were in the midst of an antagonistic separation. When I met her in October, kindergarteners had just begun to learn from my supervisor, the school social worker, various methods for solving small problems on their own. At the end of an otherwise uneventful first session, Sarah asked me what to do “if you have a big problem” and identified that problem as “gwownups fighting.”

I saw her question, naturally, as an indication of her needs, and I assumed that sorting through her feelings about whatever she heard and saw at home would constitute our work together. That proved not to be the case, however. Every week, as elsewhere, she floated around the guidance office, which was large and admittedly full of distractions: a sand table, a dollhouse, puppets, games, a whiteboard with markers lined up and ready for use. Sarah seemed far more interested in, say, drawing “a potato staring at a mountain,” than in talking about her feelings. Was it my approach that was lacking?

Despite having an excellent vocabulary, Sarah often chose not to reply to my scaling question with words; when I asked her to rate her day from 1 (the worst day ever) to 5 (a truly great day), she would walk to the whiteboard to write the answer, then draw faces around it. Her playfulness, for me, lacked transparency, and each silly face, while age appropriate, seemed to take us further away from our purpose in being there. It seemed like there was nothing to catch hold of. I became preoccupied with my apparent inability to connect with her—and as a result, failed to join her where she was.

Sarah often asked me to play hangman, seeming attracted to guessing games. (“Oh, the irony,” I thought, while she drew the gallows.) Play can be a powerful form of therapy, yes, but hangman? Eager to succeed with every client, there were many times when I questioned the value of our meetings—whether our relationship was actually serving her. I discussed those feelings with my supervisor, but aware of her parents’ difficulties, we never quite reached the point of giving up.

One Monday morning in January, I asked Sarah, as usual, how she was feeling on the scale of 1 to 5, and beside her number, she made what looked like four hash marks. “What’s that?” I asked, struck by the unusual drawing. “Scratch marks from a cat,” I was told.

In a flash, an instinct (or desperation) to follow what seemed different, what seemed new, took hold of me. “A cat!” I said. “What can you tell me about that cat? What’s the story of that cat? Maybe I could write it down for you!” “Okay…” she said and followed me to the table, leaning on it and prompting me: “Chapter One.” She watched me write my own contribution: “Once upon a time.” That phrase had always held magic for me, but with Sarah, I was to experience its power as I never had before.

In that first chapter, I recorded that the cat was named Sarah, liked to play, had sharp claws that she used to scratch things, scared her classmates (which made her sad), and was the most beloved member of her family, more so than her baby sibling, who got sick on the bed and made their mother angry.

Six more chapters followed in succeeding weeks. Each time we composed one, my young client watched me take dictation, speaking word by word so I could keep up.

This is what I learned: Sarah the Cat was lonely. She thought her claws scared her classmates; she didn’t know how to make friends. She had no one to play with at school, and it wasn’t any better at home. Though half-hidden in other details to begin with, loneliness was her theme—a fact that became more explicit as time went on.

Finally one day I commented, when our bleakest chapter was done, “I have to say, I’m feeling sad for Sarah the Cat, and I would like to spend some time thinking about things that might help her.” She fixed her wide-eyed gaze on me. “Why do you want to help her?” she wanted to know. I kept to the world we’d created. “Because I care about Sarah the Cat. I know she’s just a character in a story, but I care about her.” After the slightest pause, she said, “Because it’s really me.”

Tears smarted in my eyes, but I blinked them back and replied as if I were surprised by the fact, not moved by her owning of it. “Is it you?” I asked. “You’re Sarah the Cat?” I added in a quieter voice, “Well, then, it matters even more.”

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.

 

 

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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UNRULY, STOIC, HEROIC

One of them wore a black biker jacket; another, a bitty brown mohawk. Several could not hold still if you paid them. They were third-grade rebels, and they sat in a circle, governed by a pink-and-yellow beach ball.

The rules were simple: Whoever held the ball could expect our collective attention as he shared a piece of news, and when he was done, he’d (lightly!) toss the ball to his chosen successor. Everyone would have a turn.

That simple ritual might be familiar to those in the school counseling world—and, for that matter, to teachers—but I was an intern, and justifiably impressed by my supervisor’s brilliance in coordinating it. Her energy normally ran as high as the boys’—she’d rather do calisthenics than sit at a desk—but she instinctively tempered herself to lead by example.

As with all positive interactions, this one worked on many levels, some subtler than others. For one thing, in a general classroom situation, attention tends to be divided six ways from Sunday, and it’s easy for kids to feel less included than they might wish to be—regardless of adult perceptions as to how much time and energy they’re getting. (If attention is like a beam of sunshine, kids are like mobile plants, jockeying for space, spreading their leaves, and reaching—in whatever way they know how—toward the light.) Clear turn-taking is more valuable than it might appear to you or me, especially with boys quickly learning from the world to play it cool, be disaffected.

So the beach ball gave the boys a chance to get what they privately, deeply needed, without having to fight for it. It also gave each boy brief control—over the ball, over what he offered up, and over whose turn would come next—and subconsciously encouraged the sharing of power. Additionally, as Lawrence J. Cohen discusses in Playful Parenting, “catch” is a way of bridging the distance between males in our culture—even, I think, when played out so briefly.

Perhaps my favorite aspect of this activity, as participant-observer, was that, before sharing, each boy was asked to instruct us as to how he would like his news received. Applause? Silence? “Freestyle”? Several chose the last option, of course, and everyone was duly silly, crawling like crocodiles or shimmying or jumping like participants in some goofy Olympics. But the majority of the boys—referred to the group for their disruptive behaviors—requested silence. Heroic little men-to-be, I think they wanted to be taken more seriously.