Thursday, November 24, 2016

One Snapshot, then other Bloggers

Here's the snap:

Impatient with Patients: The What Else Is New

It often happens that someone (in therapy) will say, "I’m doing great! So much better!"

And in the very next breath it is: "Actually, then (this happened), and (that happened). But still. . . I handled it so well. . ." 

And you are waiting. 

There is a pause. Maybe even a short one, the response could even be sans pause and pow! 

The patient looks right at you, the mood has changed, the patient narrows his eyes, might even scowl, becomes a different person, his old self, for he remembers. 

"I’m just really, really angry at . . ."

and another story tumbles out, same story, same offender, or some other offender, on a good day there may be multiple offenders, persons who share the responsibility, the blame for the change in mood. Even if the patient attributes a good reason, an empathetic reason for offender behavior, the narcissistic injury stings.  

A narcissistic injury, just to digress, can motivate people to positive action, or negative, depending upon one's point of view. There is a legend about a man, Donald Trump, roasted at the annual National Press Club dinner. This is traditionally a roast, a night of humor, sarcasm, good cheer. But apparently President Barack Obama roasted Mr. Trump, not yet a candidate, and kept it up, went on and on with jokes, all at Mr. Trump's expense, they kept coming, and coming. And at first he tried to take them, pursed his lips in a smile. Then the smile went away, and his face hardened, turned blank, emotionless, flat. Then the brow furrowed, an empty stare, the one we associate with dissociating. And at some moment, it might have been that moment, now President Trump elect consciously made a decision, determined to show President Obama, to show them all, to show everyone sitting at that dinner, all those people from the press cub laughing it up. He would show them exactly who they were messing with, embarrassing. Embarrassing someone is, in some circles, a very dangerous, negative, bad thing, even a huge sin. 

That said, my mother loved it when we made fun of her, thrived on it, embarrassed or not. To her, the most humble person on the planet, the family laughing, uproariously, even at her, especially at her, was a good thing, good fun.  

But back to our story, the What Else is New, story, about the pattern, when people start positive then get off track, have no staying power with a good emotion, also known as the
I can't be happy with just that, just having had a good week, it's not enough
patternJust doing great is not enough. Therapists wonder, will there ever be enough therapy to help this patient? Defining success is the answer, certainly. Will he ever get better? Again, define better. He will, if we are patient, don't impose our values or needs upon our client. All of us resist change, get married to our emotions, and usually lean towards a favorite emotion, the one that suits us best.

This is part of the job, working with difficult marriages, especially marriages to negative emotions. And we all have our pet peeves, our interface. We dislike particular character traits, certain responses in particular. So as a therapist who happens to be a person, too, one grateful for everything good in her life, for every good day, even the bad days, grateful for the people she knows and mostly loves, even her patients, as a person who is grateful when the elevator isn't slow, or when someone opens a door for her, who is happy when the phone call on voicemail isn't spam, or a relative from far away sends an email, one who feels blessed with the opportunity to have one more free day, who is not wrongly imprisoned, immobile from an accident, or dreading the next bout with her health, not that aging is a picnic, such a therapist's feeling, when that patient shoe finally drops, when that man's good day takes a turn to an angry day, evokes, for lack of a better word, impatience.

When the zinger comes, the story about whoever or whatever it was that burst the bubble, the sense of goodness, a therapist is likely to envision the silent cartoon bubble over her head, the one that says "And what else is new?"

The good therapist rarely says that, though, not aloud, and wouldn't repeat it, is embarrassed for thinking it. Because the "what else is new?" is not empathetic, and empathy is what is called for in therapy. Patience, not sarcasm. The job is to let the patient spleen (rant on angrily) until there are no more words, because THAT is what is therapeutic about therapy, 99% of the time. Then the processing, maybe, if the patient allows, if time allows. Otherwise, we're merely to let the patient spleen.

That, so they come back. Once when I was consulting with a very high end group, an academic medical group, the director told me, "Whatever you do, just keep them coming back," and I never forgot it. "Are you serious," I asked. And he said, "Yes." This is a people pleasing job.

The odds are therapists will be empathetic, not mean. We're not going to say, What else is new? The drop of the other shoe is predictable, the same things still bother the same people, which is why the go-to response will be:
"Wow, so inappropriate!"  when it is about what the other person did or didn't say, did or didn't do. Whatever it was that made the patient, who had been doing so well, so angry, cannot be minimized, not ever.  Empathy, not sarcasm, not even a joke.  

That would be enough, that snapshot.  But it is a holiday, and folks do sit around, hunt for things to read, and it seems to me, before life got in the way, that I used to post a blog every so often and link to or recommend other blogs. That was when there was time to read other bloggers, but there's something else. Bloggers, back in the day, were not in it to find business, or maybe they were and I just didn't notice. But there was an innocence, a real creative thing going on. 

And you know, things change. Yet, there's still good reading out there, and it is formatted so well. It wasn't hard to find good blogs. So without endorsing, or even agreeing with the following therapist-writers, for your entertainment and erudition, here you go. 

Being partial to AA and AA bloggers, we have to begin with Drinking Diaries, especially this time of year, when the booze and drugging opportunities play.

And Syd, I'm Just F.I.N.E (hi Syd!)

Anita Sanz, in I've Got Your Back, on boundaries. You could say, life is like a bowl of Halloween candy, without any boundaries. You go girl.

Therese Borchard, an old blogger buddy, writes on the New Science of Exercise (and depression), because who are we kidding? Unless you move around, physically shake the lead out, the symptoms of depression, i.e., vegetating, hyper-hypo eating, lethargy, anomie, thoughts of worthlessness, hopelessness, etc., move in. Friday, do more than shop. Take a real power walk.

And Lindsay Holmes, of the Huffington Post, brilliant. Watch where you seat people at the table this Thanksgiving. But you already knew that. .

A Handy Self-Care Guide For When Politics Come Up At Thanksgiving

Kim Bowen, at The Marriage Place has some thoughts on verbal abuse. My own can't be verbalized (it brings out the warrior female, just saying). MEN WHO RAGE AND THE WOMEN WHO LOVE THEM  Also, just an fyi, all due respect, women who rage aren't exactly rare. But you knew that.

Karen Franklin, a forensic psychologist presents the another side to the crimes that make us cringe, abductions, physical-sexual assault, and a review of the numbing podcasts that chew them up. For those who don't mind taking a walk on the dark side, she's prolific.  

If you're into transitional objects, and object to the latest hysteria about how to properly put your baby to sleep, Claudia Gold, an MD has a terrific post, one that debunks the myths. Old fashioned pediatrics in the New AAP Sleep Guidelines, the Baby Box. . .Child In Mind is her blog. Thanks Doc!

And of course, if you're in the mood for a little education, you should check out SocialWorkSpeaks, where you'll find research snaps and news about mental health professions who get out of the office and do, what I call, real social work.

There are more, for sure, but you have cooking to do, or moping, and you have to love yourself either way. Happy Thanksgiving, and Go Cubs! (smiley face there)


Anarchist Soccer Mom: A modest proposal to VP-elect Mike Pence. (on abortion)

Sunday, November 13, 2016

The Safety Pin Idea

In my day you used a safety-pin to fasten a diaper. A really good safety-pin had a hard plastic head made of pink or blue, maybe yellow.

  1. A patient asked me, What's up with the safety pin? (The one on my blouse). I answered that it was a solidarity thing with minorities, people who are at risk. Then I remembered the Holocaust and that story. . . 

  1. Martin Niemöller

    In Germany, they came first for the Communists, And I didn't speak up because I wasn't a Communist; And then they came for the trade unionists, And I didn't speak up because I wasn't a trade unionist; And then they came for the Jews, And I didn't speak up because I wasn't a Jew; And then . . . they came for me . . .
    Should we be worried, fearful that the American way of life, liberty and justice for all, will disappear? Could America become more like Germany in the late nineteen-thirties and forties, or Russia, ruled by one leader, one party? 

    Rather than worry, some have taken to wearing safety pins. Those who understand this intervention like it because it is a way to communicate to vulnerable populations, to reach out. It is designed to help people feel safe. There is safety in numbers.

    Therapists like anything that fosters a sense of security and safety, anything that reduces anxiety. These little bits of hardware even have the word safety as a root.  

    It started in the United Kingdom last summer with Brexit. To cope with the Brexit crisis, those who lived in the UK wishing to show solidarity with immigrants, poked them into their clothes. Like the colorful rubber bracelets people wear when they support research for cancer, or back in the days of the Vietnam War, when wearing a black armband meant you wanted the USA out of the Southeast (the black armband a symbol of mourning), the safety pin is more than a just a fashion statement. 

    It is a fastening together of humankind, implies support for the differently-abled, victims of racism, those who have to watch out for their physical and psychological safety due to sexism, homophobia, religious discrimination, ageism, any of those ugly isms

    Historically, Americans, when stressed about social policies (look up Poor Laws) have turned to their British role-models for advice. 

    The best headline during the Brexit safety pin episode had to be Safety-pins Puncturing Post-Brexit Racism. Make it so, here in America.

    Many, many Americans are panicked about Mr. Trump's victory, worry that he will turn back the social progress of the last few decades. It is impossible to ignore the emotional atmosphere in the country, the reaction to the election hasn't let up. The days of American Political Angst started on November 9, 2016, with that big surprise, regime change. 
    Or as people are calling it, eleven-nine.
     A tweet by Bex Tayor-Klaus:   My  shows I will protect those who feel in danger bc of gender, sexuality, race, disability, religion, etc. You are safe with me.
    They lined up in Washington and New York to protest the election, to tell President-Elect Trump that they feared for the lives, the futures of their friends. The protests were loosely organized, under a thousand angry, scared souls. But better organization, better demonstrations, we might imagine, will follow. 

    We have reason to believe that this isn't irrational panic. There have been over 200 incidents of election-related harassment and intimidation recorded by the Southern Poverty Law Center, in the first three days post-election.  They even occurred in the VP-Elect's hometown.  Chants of Build That Wall echoed during lunch at a Michigan school, and a swastika decorated a storefront in South Philadelphia

    This isn't the transition some of us hoped for; it is more like the one we expected and feared.

    Thus Americans, worried that the worst is yet to come, have followed their European cousins with the safety pin intervention. 

    President-Elect Trump and Vice President-Elect Pence should put one on. It can be gold. This would reassure the American public. 

    The President-Elect could tweet about it. Tweeting is addictive, in a good way, because tweeters express their negative emotions, yet 99% of the time, nobody cares. But if he tweets, everyone cares. 

    Twitter's WifeOnTheVerge tells us what it means. This has gone viral. 

    It makes sense. Holding things together is a safety pin's raison d'etre, if only the hems of skirts, and diapers. People vow not to let go of their friends, not to abandon those in fear of being cast-off, sent to another country having committed no crime other than being themselves. So the safety pin is a symbolic coping strategy, works with any wardrobe. See the latest in fashion examples.

    The President-Elect could sell them in different colors, as long as he doesn't make too big a profit. 

    But probably that won't happen; he won't get on board. He might even respond with a negative comment, as opposed to one that reassures. Still, some of us hope he can rise above the pre-election negative verbiage, now that he is the declared winner. 

    He should know, however, that there are likely to be protests, that people might come out in droves, fill the city streets, shut down government buildings, when he puts policies into place that turn back the hands of time. 

    We might see the 
     National Guard again. How strange is that?

    It won't be like the 5 million in Chicago who came out when the Cubs won the World Series. Now that was a rally, but a victory rally, not one communicating anything to anyone except good cheer. The sheer numbers in the picture below show us how, when millions of like-minded people get together, (and wear the same colors) it can be a thing of beauty. The rallies to come are more likely to be demonstrations of civil disobedience, and they might not be so pretty. 

    Even if the President-Elect doesn't wear the safety-pin, that little piece of nearly extinct hardware that saves us from embarrassment when something tears, and once held diapers together on babies,  

    At least one of us will. 
    The safety-pin on a doctor's blouse



Wednesday, November 09, 2016

President-Elect Trump

I know, I know I said it.
I said that both Mr. Trump and Mrs, Clinton needed therapy (last post). People are taking down their FaceBook accounts because of things they have said publicly, and this should worry me. 

But that was yesterday. And the theme of this blog, remember, is that everyone needs therapy. So it isn't an insult, okay?
President-Elect Donald Trump acceptance speech

Today, the day after the election, I'm thinking more of the President-Elect. No matter the personality we saw during the contest, he knows this country better, more intimately, than any of us. We underestimated him.  

And this intimacy, this knowledge, is the reason he won the election without contest.  It is why he said he would give us hell if Mrs. Clinton had been elected, that he wouldn't accept the election results. He knew. He had his finger on the pulse of America all along, when nobody else did. 

America, to most of us, has been the America that is outspoken, everyone shouting at everyone else on some media or another. Yet in the big bell curve, in reality, not everyone wants to be the center of attention, and Mr. Trump spoke to that majority. President Nixon called his electorate the Silent Majority. The shape has changed, as has the demographic. But people wanted change, and they had no place to channel that desire until Donald Trump walked into their lives.

And that’s a type of social intelligence, is it not? Understanding the people in the country, the forgotten ones, those who have for years felt disenfranchised, unimportant. It could be interpreted, rightly, as intellectual, even emotional empathy. We’ll soon see if such empathy is universal, if it spans across the universe, if it is inclusive

People are really worried, or so we hear on the news, the radio interviews. Many woke up this morning, and hearing the outcome of the election suffered features of panic attacks— literal panic attacks-- shortness of breath, heart palpitations, dizziness. 

Jews just make jokes about being sure their passports are current. It is how we think.

The results seemed remarkable, unbelievable. For the polls had us ready to crown Mrs. Clinton, and whether we liked her or not, we had prepared for that, her resumption of Clinton rule. .

It was the surprise, the upset, that set off an arousal response, the panic, as much as the fear of what a Trump presidency might look like. Those who have learned the art of meditation, or emotional management might easily reverse the negative symptoms. A tried and true intervention is to remember not to dwell on the past, and equally as important, let go of the future. Only the present, what we are doing in a given moment, is within our control. Not that we can't work towards the future, put plans into place. But under the influence of anxiety, the here and now serves us better. Stay there. Do what feels good, right. Live one day at a time. Maybe pray. It is hard, but wrangling thoughts is a major component of serenity. 

Or just watch the President-Elect's acceptance speech. His voice, his posture, his very persona are reassuring, convincing, healing. There is none of the narcissism he’s been labeled with, none of that NPD, or Narcissistic Personality Disorder* that scares so many. Our new president looked and spoke Presidential. 
“It is time for us to come together as one people.” 
He doesn't say, "It's time to get to the work of deporting people." He talks of uniting, which is what new presidents all say after an election, but some of us expected another Donald, the one that is unbridled, who can't resist a snarky remark. But no, not a single I told you so, nothing negative about anyone, certainly not Mrs. Clinton. Only magnanimity.

If you read my last post, the one about social justice, you might remember that human rights activists and social workers do what they can to make things happen, to change deplorable conditions. Dr. Luis Zayas told an auditorium full of academics at the Council for Social Work Education annual program meeting that cynics and conservatives believe there will always be injustice, that it is inevitable. Get used to things being hard. But the social work response is just the opposite: Injustice is intolerable. 

So here's the big challenge, and a message to President-Elect Donald Trump

We’re all in agreement for the first time ever. Mr. President-Elect. It is time for us to come together as one people, a task that seems impossible. But the divisiveness, the hatred especially, should be intolerable, especially to you.

Accomplish that, make the seemingly impossible, possible.  Because you have the power to do this. Create an inclusive culture, one that bring us all together, and don't dial back the progress of your predecessors. Do it, make this country great again, as only a strong leader can. We are counting on you. Many fear you, disperse the fears. We could use a mentally healthy, loving United States of America.

And we know you hear the country's voices, that plurality, crescendo above us, above you. Make good, Mr. President-Elect Donald Trump. Go for it, the one people idea. Even if it wasn't exactly a campaign promise.


P.S. For those readers who feel this is a totally, ridiculously naive essay, I say. . . maybe.
For a much more rational opinion, one based upon everything we've seen in the past year's campaign, not based upon hope and a belief in the potential of man (when reaching potential, true potential is within his reach) read David Remnick's essay An American Tragedy, in The New Yorker. 

*Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by (five or more) of the following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

Tuesday, November 08, 2016

Social Justice: Orphan or Exile

Most of us have voted by now for the next President of the United States. The candidates have been talking for months about many, many issues, but mostly themselves, talking about, and defending themselves.

If this were not an anonymous blog, I'd offer each my card.

Social workers are generally democratic, and highly educated, and when educators get together, some 3,000 educators, as they did last week for the Council for Social Work Education (CSWE) annual program meeting in Atlanta, the synapses in the halls of the hotel burn so bright, the place might just burn down. (Social workers like to speak in hyperbole).

When I told my son, who I consider a balanced man, about the topics presented at CSWE's #APM16, he opined,
"Wow, you guys must be the most pinko-liberal educators in the country!"
Maybe. Yet we are a diverse group, not always predictable, and despite the mostly liberal leanings, nobody has it in for social workers anymore, not like the late Mike Royko did. He loved to poke fun at us for our politics. And our codependent personalities.

There are good reasons for the field's politic. Social work missives begin in the here and now; they're reality-based, not like TV reality shows, which are scripted. Social workers hear heart-breaking stories, are personally invited to visit, to see inhumane, squalid living conditions. Poverty. Powerlessness.

The hearts stir. Dr. Luis Zayas, a keynote speaker from University of Texas, Austin, alludes to hearts and stirring in reference to the difference between conservatives and liberals. Cynics and conservatives believe that social injustice is inevitable. Injustice say conservatives, is inevitable.

We say it is intolerable.

This profession is the one that won't accept the many rational reasons, all those whys, why things cannot be done

Once stirred, social workers organize, swing in the direction of protecting human rights, service administration. They invest time and energy, money, to accomplish good things, big things. Maybe even something along the lines of, let's just say it, social justice.

Dr. Zayas is this year's choice for CSWE's Carl A Scott Memorial Lecture.
He's here to teach and to inspire.

So he tells us that social workers, like human rights activists, take on tasks that aren't even immediately tangible. Their work is not all that different from law enforcement professionals, people who run towards trouble, danger, not knowing what they're even looking for.

This teacher is a poet. I'm buying his book.*

He speaks of immigration--without the need to mention Mr. Trump, or his wall. The word bites about the lecture:
The immigration enforcement policy and practices undertaken by the United States in the past two decades has . . .affected the health and mental health of immigrants and their US.-born children and of refugees seeking asylum from the violence and lawlessness of their countries in Central America. . . violating human rights and turning our backs on social justice.
Even more enticing than the hotel pool, which was nice, but not that great.

The veteran social work educator points immediately to President Barack Obama. The President didn't start the deportation mess, but he didn't help it, either. In the past ten years hundreds of thousands, no, an estimated 3 million! families have suffered the consequences of deportation. They had to leave the United States of America. Leave this, their home.

And for every two deportees, one had a child born here, a birthright child. That makes 1.5 million children, at the very least, dispensable.

Liken it, Dr. Zayas humbly suggests, to Sophie's Choice (not the equivalent, but still) or King Solomon's decision, the one about the baby, minus the compassionate ending.** In Sophie's Choice Meryl Streep has to choose which of the two of her children will go to the gas chamber, and which to the work camp. One to an immediate death, the other to slow starvation.

When the unthinkable happens, when a parent is to be deported, citizen children become either orphans, should they choose to stay in this country, or exiles, if they choose to leave with their parents. Orphan?  Exile? Not much of a choice.

Children are the future (someone sings that), but you don't have to be a clinical social worker to know that their past will play a part in that future. Either of the two choices, orphan or exile, will affect their lives immeasurably.
Exiled means not to disappear, but to shrink, to lose the sense of American citizenship. An exile might even associate with another national identity, turn against America. The law, our law, creates the terrorist.
Orphaned implies losing the daily physical presence, love, attention of parents, even if the parents are alive. Who is around for protection?  
Dr. Zayas tells us the history of the deportation process. It doesn't happen overnight. First there is detainment in what are now called "Family Residential Centers." You can find them in the Texas towns of Karnes, or in Dilley. These started as detainment camps, operated by Corrections Corporation of America, cash cows receiving $500.00 a month per deportee from the government.

Our tax dollars at work. Detained there? Over 2500 mothers and children, dispatched to cold, dirty cells, like prisoners of violent crimes. Cold and dirty. Mothers and children. That shouldn't resonate with anyone.

With a bit of research the detainment situation in Texas had come before the courts. Social justice advocates found a precedent, the Flores Settlement Agreement of 1997, which governs the standards for the detention, release, and treatment of minors. 
The court ruled for women and children.

But the centers were merely renamed as group homes, licensed child care centers, Family Residential Centers, and the conditions stayed much the same. When this came to light (via social justice advocacy, again) publicity followed. The head of the Texas Department of Child and Family Services resigned. Things are better, now.

If you're a cynic or a conservative, you think things can't change. If you're a social worker, you think: Sure, they can.
A deportation facility (family residential center) in Karnes or Dilley Texas
Immigrants who come to America illegally say that it is a difficult choice. They know that it is illegal, sneaking past authorities to cross the border. Yet they are leaving a world filled with immorality and violence, so leaving that feels like the moral choice for children, a moral decision. And threaded into that decision, some will tell you, is a vow never to break the law again, not once they make it here, after God has granted them a better life, opportunity for their children.

That's the way it is. That is how people think.

It is next to impossible to seek asylum, impossible to prove to authorities, that lives are at risk in Mexico, or Central America, wherever, if you cannot speak the language, have no money for a lawyer. The thinking is that our immigration laws are the ones violating moral principles. We have a legal system in conflict with itself, immigration law versus family law. Family law has always been predicated by the best interests of the child.

So what's an interested activist, a liberal (pink or not) social worker to do? Not necessarily about this, but about anything like this that feels unjust?

Well. . .

Research, if you're an academic. But don't rely on academic publications, no one reads those. Get into the papers, shoot for The New Yorker.   (Dr. Zayas, heads up! Do that! They would love this story!)

Take the issue to congress, condense immigration to a paragraph, perhaps the idea that we are creating terrorists, not harboring them.

Do what you can to educate the public. Blog, write an op-ed, get on the radio. A podcast. NPR. This American Life.

Testify for clients in court, have hard data with you. Or partner with other advocates, get involved in a class-action lawsuits, amicus briefs, testify to your legislature.

These ideas sound so vague, so inaccessible, so out of reach to the average social worker.

But with a little energy, a little time, anything can happen.


*Luis Zaya's book: Forgotten citizens: deportation, children an the making of American exiles and orphans

**You might remember the story. Two women give birth the same day, but one baby dies in the middle of the night. The woman whose baby died grabs the healthy infant. His mother objects and they come to the king. King Solomon proposes that the women slice the baby in half, it is only fair. One woman, obviously the baby's true mother, objects, tells him to give the baby to the other woman if that is the only option. The king knows, now, that she is the baby's mother.

Thursday, November 03, 2016

Cubs Win!

I watched most of the games, I'm embarrassed to say. Therapists should go home after work, tend to the people in their families (second shift), have a quiet, newsworthy, intimate dinner with someone they love. Be an example to the community. Don't shame-faced tell their friends, Yeah, at the end of the day. . . I watch the Cubs.

But who wants to talk to anyone, in the evening? We want to change into sweats, turn on the TV, and maybe, just maybe, if there's one on, watch the game.

There's a knock on the door, it could be a friend who wants to power walk. Would this not be the better thing to do? No, it would not, you gently explain. You see, the Cubs are going to the World Series this year. You'll see. And this game counts.

Then you go back to  it,  and during commercials toss up a huge salad, maybe bake a potato, check your phone, texts, email. You might even return some calls, straighten out drawers, even a closet. You might do an entire aquarium water change, all the while, the game is on, and the volume is up, unless you had to mute it to actually talk.

It was hard for me, when my mother was alive. She wanted to talk every day, but mostly, she wanted to listen to me, telling her about my day. If the game was on, not so much of a problem. That you can do, watch a baseball game, while talking to your mother.

At the end of the game the guy who is calling the game, maybe Pat Hughes, Ron Cooper, Jim Deshaies or Len Kasper, would shout out at the top of his lungs, CUBS WIN!!!!!!

What a summer this has been for Cub fans. You'd see one, a fan wearing a hat, maybe while waiting for a bus. You would nod and say, This year for sure!! And both of you smile.


I registered for a conference, the Council for Social Work Education's Annual Program Meeting (APM16) in Atlanta, (CSWE16), had scheduled my flight for Wednesday night, last night, months ago. It never occurred to me to check the schedule for the World Series. And wouldn't you know, the last game, the most important game of the year, the deciding game of the World Series, would begin at 7 pm, when FD and I would be in the air.

So I downloaded all kinds of apps to stream it, and told myself the flight would be late and I could see the game in the airport, but nothing, nothing helped change this most powerless, angry, futile feeling, that we would not see that game, and seeing it in the repeat would not be satisfy.

My son-in-law invited us over to watch the game and I had to tell him I'd be in the air, and he texted back and said, "You're daughter just called you a loser. CUBS!!"

It woke me up. Sometimes someone has to speak the truth.

The backstory is that I had been navigating the app for the conference for a few days, and couldn't understand it. Anyone who knew the organization better would understand it, but having been focused on learning about mental disorders and how to help people who suffer because of them, education, the science of educating social workers, went fallow. So I didn't realize that the modules offered for Thursday didn't even apply to me. I didn't have to be there until Thursday night. I could definitely change that Wednesday flight and hotel reservation.

So Wednesday morning, as soon as I could, I checked United to find that there were plenty of flights early Thursday morning, and they were only $99.00. Sure, we might have to pay to change, but so what?  People paid thousands to get a ticket for these World Series games. I could certainly pop for a few hundred.

FD agreed.

And United, as if they understood what this was all about, was totally on board, waived the change fee.

We popped some corn and brought the salad to the family (those without little babies) party, surprised everyone.

When I told the other kids about changing the flight, the ones who could not be with us, one of the boys merely wrote, Respect.

And when we heard that final, CUBS WIN!!!!   well after midnight, I have to tell you, there was nothing in my experience, nothing quite like it, no words to express. The feeling.

We're waiting for the plane now; there are CUB hats all around, very tired CUB fans in the airport, and I've go on my light blue CUB sweatshirt, and that feeeling, it's in my chest, it isn't going away. And I know it isn't the same anxiety that I get when thinking, "We're gonna miss this plane." This is a good one. This is excitement.

It used to be crazy to be a CUB fan, but it's not in the DSM 5, and nobody can doubt this young team of very talented, highly watchable, men are likely to give us a great run for it next year, too.
It has been #GoCubsGo for months now, and I promise I'll stop.

Next year, however, I buy the white and blue flag.


Thursday, October 27, 2016

Boy, You've Got to Carry that Weight

It isn’t easy navigating healthcare today, finding the providers you know and love in a new network. You want to continue with your therapist, but when you thumb through the lists of mental health providers, no surprise, she's not there.

It hasn't been easy for those of us on the provider side, either. When the Affordable Care Act passed, we knew that we would be denied claims from these seemingly wonderful, spanking new, mega-cheap health care plans, especially the ones offered by the big companies-- United Health Care, Blue Cross Blue Shield, Aetna, Humana. Some of us didn't want any part them. We told our patients: Before you sign up, do some research . .  if you want to keep this thing we have, going.

We had no idea (still don't) whether or not insurance would pay us for services rendered.

Then it began to happen with regularity, and it continues to this day. An established patient would give us a choice: Do you take this insurance? Or this one? 

Then she would explain: My boss says I have to choose a new one. These are the only plans they've got.

Somewhat shaken, a provider might gently answer:  Likely neither. But call the number on the back of the card and ask for customer service. Mention me by name. See what they say. 

Providers like me felt compelled to add the ugly truth; Oh, and even if they say I'm on that list, the answer might still be, No, they're wrong. They make mistakes, and if that happens, I know it sounds bad, but you have to be prepared to pay out of pocket when my EOB comes up bubkus (Yiddish for Zero paid to provider).

How does it happen, that the customer service rep at the other end of the line deliberately delivers the wrong information? The answer lies in the lists. They are likely using an old provider list. Providers drop out, but companies don't retire our numbers. We're still on the mental health provider panel, although we shouldn't be. Is it intentional? You have to wonder.

The situation puts us in an adversarial position. We're the ones having to explain, post facto: Maybe I'm on the list, but I ended my contract with that company a long, long ago. If they don't pay, or don't pay enough, you'll have to cover the bill. I'm so sorry. It stinks, I know, and but I'm pretty sure that EOB will return with a big fat zero next to Provider Paid.

We sound like the broken records we are.

Suddenly a beloved provider is the enemy, a source of patient stress. We're stressed, too, as providers, because we knows we're stressing the people who count on us, people we would much rather commit to helping through their troubles. But we also know that if we work for less, if we aren't paid what we're worth, we will resent the work and the patient, and likely that will manifest, show itself somehow, in some subtle way. Here come the negative Yelp reviews. Not good.

For those of us who had trimmed third party payers well before the act passed, shaved them down to only "some Blue Cross plans" Obama Care has been less of a challenge. We simply denied new patients with insurance we didn't recognize, might say, I only take a few of the Blue Cross plans, sorry, but there are great people out there. Find one. Because there are.

We could see the writing on the wall years ago, that the only ones making money in this system are the CEO's, executives who are not paying self-employment taxes, as are all of the mental health practitioners in private practice, taxes that slice into our earnings significantly (it is as if we pay social security twice-- once through our wages, like everyone else, but also as our employers, who happen to be ourselves; we pay that other half of the social security net-- we're essentially dinged twice).

So we dropped out of the many provider panels that had never paid us enough, considering our educations and experience. Then we determined a tolerable fee schedule, fees for service that we could live with, not resent, that a middle class client, someone likely to take his family to Disney World for vacation, might be able to afford. We would see patients less often, perhaps, but our time would be be well worth it, quality time. It would be that, or refer those with "bad" insurance" along.

Someone like me, who once would see a couple weekly, would cut that back to every other week, or even monthly when insurance went to the wind. I'd suggest that each partner use the new insurance to see someone in their plan, get individual help for the things we had been working on for some time. Then, when we could, even if it would be once a month, we would catch up. They would pay out of pocket. If you have the volume, you can be creative, do that sort of thing.

But mostly we found a few groups, or a few good insurance plans, and made sure that the patients we would see affiliated with those.

Whatever we put into place, whatever new fee schedule, however we vetted insurance, it can backfire when we're talking about really sick people. Some patients really need that weekly checkup, and they won't be able to make our magic number when the insurance changes, or the job disappears, and it is a matter, truly, of life or death. How do you tell someone who wants to die that he needs to find a new life preserver?

As soon as you get the news from the patient, I've lost my job or I've had to change my insurance and you're not on the plans, it is a very big problem. It shouldn't be, this is hardly a terrorist attack. You might secretly even want the patient to move on, not liking the responsibility of carrying that weight, but it is your weight, and you know how to carry it, and you know, deep inside, that nobody knows it better, or will do it better, than you. Not right away.

So you say, We'll work something out.

And the patient says, I need to know. How much do you charge, anyway?

Because his insurance has covered all of it, until now, except for a co-pay of $10-$50.00.

So you say, My fee is more than you will want to pay, even if you have saved your pennies*, and I still have to see you every week to feel comfortable being your therapist. We have to work something out.
And the patient says, What does that mean, we have to work something out? How much is working something out per week?

Then you do some brief calculations in your brain, might offer: What if I see you for a half an hour a week for $60.00?

And the patient says, I can do that every other week. 

And you say, Done. But we talk for a few minutes on your lunch our on your off weeks.

And the patient says, But what if I don't ever get a new job? What if I run out of money?

You smile and you say, I have confidence in you. I'm sure you'll find a new job.** And whatever happens, we'll work it out. There's always a solution. 

The clincher is the confidence, having confidence in the patient's resilience, and it is much easier to do that with young patients, when we're talking about finding another job, even young patients with bad disease, chronic major affective depression, for example. They get hired faster, even with severe symptoms (no, they don't talk about those in interviews) than patients in their fifties and sixties with less oppressive mental illness.

In my practice, just this past year, it has happened four times (really, four times) what I'm calling sudden treatment-coverage interruptus. Each patient had sought me out, initially, with serious suicidal thoughts or plans, and we had worked for months, sometimes for over a year, grappling with recurring symptoms. When the insurance stopped, or the patient was let go from a job, a crisis loomed. But in each case, following that lag, sudden treatment-coverage interruptus, (not service-interruptus), after some months, the patient either found a new job with decent insurance, or transitioned over to another therapist. We held hands along the way. It felt good, not saying, prematurely, goodbye.

The affordable insurance climate is, in a word, formidable. But therapists have established practices, signed up with people well before the President signed the bill, made the changes, and in those very first meetings, we committed to helping people, or to helping them find help. We can't just close our eyes, run from the insurance crisis, when it presents itself, leave them hanging when the going gets tough. And when we don't do that, what we're seeing in the aftermath of it all, having held on tight, is that not only did our patient grow from the ordeal, toughing out the emotional adversity, but we providers do, too.


*We know if they have saved their pennies or have not, generally recommend that they do when they talk about things they think they want to buy, comfort retail. it is a part of the job, talking about one's relationship to money.

**When the patient is in late middle age, the you'll find something is replaced with, something will change for you. Like they may have to move in with someone, be of service, eat a good deal of pride.

Sunday, October 02, 2016


It was an afterthought. 

I was writing about dysfunctional obsessive behaviors: drinking, drugging, gambling, sex, over-eating, and watching way too many baseball games on television.
Chicago Cubs WIN Flag
he usual coping strategies. And I added, as an afterthought, I considered, just for a moment, prayer. 

But stopped right there. Because, can we really pray too much?

This is the time of year that Jews pray for the welfare of the entire world. Our attention, highly introspective, drilled into us by parents, teachers. God is thought to be closer, He, She's sweating the details, paying attention, trying to see who's been naughty or nice. Santa, sorry, is a total steal.

In the synagogue daily, for the past month, or maybe at home, if you live with a musician, the blow of the ram's horn, the shofar, is a wake up call. Wake up! Think about what you really value, think about the important things. Pray for what matters, strive for better, reach to be a better person, extend yourself. We say that God judges the world, all of it on Rosh HaShana, the Jewish New Year.

It begins tonight, and the Days of Awe last 10 days. Last month, the prequel. This isn’t a party holiday, it is serious. Those of us who observe it don’t drink much in celebration, don’t want to be caught napping. There are loftier things to do, learning in particular, praying, and that's how we want to be seen, as if God, considering us for the coming year, will merely think of us this way.  

There have been extra prayers penitential prayers, beginning before the holiday, continuing until Yom Kippur, the Day of Atonement. People pray early in the morning, late at night, fall into bed exhausted. Why bother with this? Isn't praying three times a day enough?  Either you believe or you don't, is the answer, and if you believe, then you know there is much to pray for, much that neither Donald Trump or Hillary Clinton can or will even try to do a thing about. 

Our lives, the lives of the animals, the fish, the trees, gardens, insects, the atmosphere, the earth's resources, the weather, every income, our stocks, our jobs, you name it, everything is determined, the fates, sealed for a year. It is a one-year contract, designed to keep us on our toes.

Because otherwise, we take everything for granted. This is why therapists try to get you to buy into the idea (with several exceptions) that a little stress is good, a little depression, your problems good too, because these annoyances force our hands, inspire growth, creativity, change. Even learning how to manage emotion, the physiological-psychological baggage that goes with stress, all that painful emotion, is a good thing; managing it, a rite of passage.

When it's not too much.

When it is, when things get really bad, that's when some of us, if we pray at all, start to pray with a vengeance. When things are very bad, people who pray, pray harder. They ask for others to pray with them, for them, for their families. And some of us who never prayed before, begin. Coping in this fashion tends to help us find solace, a little bit of comfort, even if we don't get what we pray for. We will say, You can’t pray too much, you can only pray more. Free will? Sure, but in the end it isn't such a bad idea to ask for help

No atheists in the foxholes.

Once I had an acquaintance who, you could tell, prayed daily, maybe three times a day (since she's Jewish), with intention, meaning attention to the words. People in her synagogue thought this because at weekly Saturday services she spent a long time during the silent recitations of prayers, and she cried, sometimes a lot, sometimes just a bit. So most of us assumed that she had problems, and we guessed at what they were, but we all assumed that she truly believed in the whole idea, the idea of prayer.

Just an aside, in Judaism prayer is important, but actions are more important. During these High Holy Days we're judged on tefilah, tzedukah, tshuvah-- prayer, charity, and a return to doing what we’re supposed to do. (We're assumed to have messed up somewhere). Charity and return are behavioral, not contemplative, and an effort at all three at once holds the keys to life in the coming year.

But back to our story. So one day I noticed this friend wasn’t so intent on her prayers, that she seemed much more relaxed, chatting it up with the other women who sat near her. After services, the women were talking, just idle chatter about books and television, and she joined in. She mentioned that she liked some show that actually bothered me, it had so much gratuitous sex and violence, and I teased her, And here I thought you were so religious. 

She laughed and said, Aren’t you?

Sometimes we are, sometimes we're not. It is the way of all people who appear to be religious. 

Chances are, things picked up for her, something lightened her load. Or, she just burnt out, all that devotion, too much to keep up. She would say, my guess, is that as a coping strategy, prayer can be a masterful, powerful form of meditation, focus. Many of us concur. Still others say, It is more than that. It is life or death.

We can't help but hope that when we do pray, when we talk, when we put an invisible concept in the room, as if our words are under consideration, it will make a difference. There's nothing dysfunctional about that, obsessive or not. Perhaps insisting that others do the same, be the same, is.

Have a happy, healthy new year my friends. May God judge us leniently, give us a good one, rich and meaningful, with snapshot memories that move us to good tears, a year that only gently shakes us out of our comfort zones, motivates us to do whatever it is (for I believe it is different for everyone) that our Higher Power wants us to do.

And it wouldn't hurt, honestly, since She is paying attention, if she waved the blue and white WIN flag, and the Cubs win the World Series.