Thursday, July 16, 2009

Traffic and Weather

I’m taking a 7th inning stretch, moseying into my colleague’s office to say hi. She’s aggravated because patients aren’t showing up.

“Do I charge them?” she asks.

“For sure! Charge ‘em!”

I’m in a take-no-prisoners mood, who knows, why, but have spent a good deal of the day working without a break. And the day started at the hospital, checking on my father. Every morning this week is at the hospital, which I don't mind, but I've been driving there, which is bad enough, and hate the parking lot, going around and around and around and around and around.

And there's no time to get home after the visit to change clothes to ride my bike to the office. There just isn’t time to waste.

So in general, I’m a little out of sorts. And some of the crank, for sure, is my father’s because he’s the helpless one lying around in a hospital bed.

I haven’t even told my colleague this, none of it, because (a) there hasn't been a lot of time to talk, and (b) I don’t want to talk about it. That’s what a blog is for anyway.

She says, “Charge them? How do I charge them? Should I call them up on the phone right now?”

“Don’t be silly! When you can talk to me? You'll get a call for another appointment and will say, ‘By the way, you know you owe me for the last visit. You didn’t show.’

And your patient will say, 'Oh, drat! I forgot!' or will spill out some excuse. Then you'll give that little speech we give." (Most professionals have a variation of this one.)
Sure, I understand, but you're supposed to at least call, we had a deal, even if you're sick, or have a funeral you have to go to, and you stole another patient’s time, because there's always someone who wants a cancellation. But no one could take your spot because it wasn't open cuz that didn't happen. That's why we charge, it's why I charge. Makes people more sensitive to other people the next time.
"You deliver the lecture," I tell her, "get paid and are no longer resentful and grumpy. The world is beautiful again."

“I’ll try it,” she says.

She might, but she probably won't charge. We social workers can be all mush.

ANOTHER STORY

So today I say to FD, “I’ve had it with driving. I’m riding my bike to the hospital and from there I’ll ride it to work. I’ll leave early so there's plenty of time.”

He’s skeptical, “Uh, that adds 11 miles to your bike ride.”

“No way,” I say. “And anyway, it’s all bike trail.”

For the most part it is bike trail by the river, meaning easy riding, and the only real danger is urban cougar, the feline species, and an occasional tricyclist. (By this we mean child on a tricycle, not someone on an antidepressant).

“You’ll see how far it is. It’s going to be tough. I can drive you, do what I have to do, then pick you up at the hospital. Then you can drop me off at work and have the car,” he continues.

“Senseless. It’s a beautiful day. Birds gotta’ sing, girl’s gotta’ fly.”

And it is fine, it truly is, for the first mile and a half. I’m very out of shape, have had no time this summer to get on my bike most days, and when I have done it, it’s been slow going. I’m not the person I was even a year ago. Enjoy your youth, my friends.

But I get to the hospital, no worse for the wear, and lock up my bike, take off my helmet and take a deep breath. I’m a half an hour late and for sure have missed the doctors. I want to talk to one of them, at least. Anyone on the team will do.

I get up to my father’s room and he’s rearranging the hoses and tubes that are sticking out of his arms so that he can sit down comfortably in his recliner. The drips are full of diuretics to get the excess water out of his body. The kidneys aren’t working, the heart’s not working, nothing’s exactly doing what it’s supposed to do. He’s braced himself for disaster and has been very philosophical.

“The food here is good, but I’m not hungry.”

“You’re sick,” I say.

“Yeah.”

“And it’s sickening, right, being sick, so how could you have an appetite? It would be weird to have an appetite, I feel.”

He laughs and shows me the paper and pencil review he’s given the nurses and the doctors so far. He has been very positive, very happy with his care-givers.

“I love it," I say. "You know, there are people who won’t give a positive review. No matter what, they will find something wrong with the people who are just trying to get through their day, trying to be helpful.”

“And those people are wrong!“ he confirms quietly. “They should write a good review anyway.” He would tip even the worst waitress. “Even if they’re terrible you tell their bosses how good they are. Then they’re not so terrible. They get better.”

Right, Dad.

We banter about nothing, and I realize that if I don’t get back on my bike I’ll be late for work and can’t let this happen. Mom will take the next shift pretty soon, anyway. I buy a bottle of water at the snack bar before leaving.

The ride to the office is LONG (about seven miles, FD is right on the money) and I have a sandwich in my backpack and I’m thinking maybe I should stop and eat or have a drink. There are plenty of park benches calling my name, but worry that if I do, and something happens, maybe a flat tire, I’ve wasted time eating and drinking. I hate being late. And I’m not hungry, anyway.

But I get to work in plenty of time and my fish (2 baby maroon clowns) are thrilled to see me. I feed them and they think they've died and gone to heaven. There are patients who have been calling all morning long on the office line, my cell phone, too, that I should call back, so I get to that. Eeeny, meeny, minee moe.

By 5:30 my back hurts and I reach for the Advil, pop open some email, too. One says in the subject line, 'I'm venting.' Why not? What's a therapist for?

There’s one more appointment to go, a 5:45. I get the call.

“Doc?”

“Yup, where are you? Caught in traffic?”

“Yes, how did you know?”

“I’m a genius.” (I don’t say this)

The city has been impossible, one of the allures of biking. Chicago has a short summer and construction begins and we end, so to speak, with the good weather. It is possible to spend the best hours of the day behind the wheel.

“Oh, a little birdie told me.”

“By the time I get to your office our time will be up,” he moans, remorsefully.

“We can talk on the phone,” I tentatively suggest.

“Okay!”

“But you’re in traffic, I just remembered, and I want you to pay attention to the road.” And I’m thinking, I can leave! I can go home!

“Can we reschedule?” he asks.

"Lemme look."

I find him a spot next week, knowing there's money lost here. I tell him, “I’m not charging you.”

“Thanks!” He’s so happy.

“Have a great night.”

Fact is, I could have charged him, and he would have gladly paid me. But he is powerless here and I am happy here and why would we punish either of us for either of those things? Hey, and he's called.

I pack it up and am out the door. It’s threatening rain, but you know, it’s that light summer rain that doesn’t bother you, the kind that sort of wakes you up, reminds you what it’s like to be a kid again, not worried about things like rain.

therapydoc

Wednesday, July 08, 2009

Termination

I think-- gold watches, retirement parties. Cake.

Or the divorce party. Gonna' wash that man right out of my hair (a real oldie, you're not expected to know it).

The due a person gets for surviving a long association with an institution, sometimes trying, sometimes rewarding. Like marriage or work, or any serious social commitment that’s lasted long enough to feel. . .important.

Endings that beg formality.

Graduations, for example. FD hates going to them. He says, "What's to celebrate? You're just going to have to go back to school in September. There’s always another school."

He’s of the opinion that you learn more on field trips and reading encyclopedias. So he doesn’t get it. Would you ever stop learning, he asks? In his world there’s always something more, something new.*

But for some of us, our relationships are the most exciting something new in our lives. We don't just exchange phone numbers to say, “We’ll keep in touch!” and then not keep in touch. But it's harder, we know, once we've moved on, followed different paths. We become relationship-lazy, perhaps one of the reasons graduations are the perfect places for goodbyes. Give the work, the relationships, their due. And move on.

Then once we've settled down, established some roots, we find we're on the move again. In this economy some of us are moving back to our families of origin.
Where else am I going to go, now that I have no job?!
And some of us are moving away, taking the only jobs available, leaving extended family behind.

A friend of mine has a daughter who is being transferred a continent away, taking her spouse and children with her, the chutzpah, seriously. My friend, isn’t going to be hopping on planes to see her kid, she can’t afford it. This is a separation, not a termination, but it sure feels like a termination. Try convincing her otherwise. I wouldn’t begin. Sometimes people just need to spleen anyway, you know, let the tears roll.

When family moves away, it can hurt pretty bad.**

When it's friends, it might hurt, but the impact has to be different, less intense. We have to be happy for them, stay positive and profess, “We'll still get together, we'll visit. Now we have a good excuse to travel. A free hotel in a new city!” Like this is so easy, traveling. So pleasant, And so affordable.

Years ago, when my best friend (we had one of our kids on the same day, different hospitals) told me she was moving to Miami, I looked at her and without a trace of sadness sighed, “Nice knowing you. I’m terrible at keeping up, just being realistic here.” She wasn't pleased. But some of us get used to separations, terminations, young.

In our case, our time together was regimented, limited really, to one day a week, Saturday. The Jewish Sabbath consists of 25 free hours of not answering the phone, not turning on the television, not traveling, definitely not working. It's more like eating and drinking most of those 24 hours, singing, visiting friends, learning, and going to the synagogue to pray. I know, it's a tough life.

But once she moved I knew she wouldn't be a part of that anymore, that we would have to find time during the work week to talk on the phone, and that wouldn't happen. As it turned out, soon after she moved, my parents bought a condo in Miami. So now, when I visit them, my friend and I either get together for dinner or we talk about getting together, and that’s fun, too. It's like the proverbial call from the cousin at the airport between flights. "I'm here in town! Just called to say hello!"

All this before email, you know, all this drama. Now, we say,
"We'll email!”
Cause we have so much time for this, time to write back and forth about what happened today, yesterday, the past six weeks, six months. But some of us do pull it off, and we know how special it can be. But it’s not easy to keep up, is the truth.

So it can be tough, terminating, facing the reality that what we had together has to change, will go bye bye forever, lost to the past. Those of us who accept it don’t mind calling it what it is, termination. We say, “Goodbye, for now!” and celebrate the relationship we’ve had, redefine one for the future, try not to drop off the face of the earth, and when we do see one another again, try to pick up where we left off.

Negotiating a termination, saying goodbye well, means communicating what to expect from one another. What we would like, optimally from one another in the future. We'll expect more or less communication, depending upon the relationship. We say in therapy that there is no such thing as no communication and that may be true. But people over-diagnose no communication, tend to assume too much. They think,
"Where did you go? You haven't called. You must not like me."
Oy. Maybe nothing could be further from the truth. The squeaky wheel gets the oil. Our time isn't our own. There may be none. There is so much to do. And depending upon our histories, it may be hard not to take it personally. No call back, no letters. We'll perceive that as abandonment, an absence of emotional attachment, not enough, surely, to get the pencils writing, the telephones to ring.

But each of us has probably rejected more than we know, terminated relationships without a thought to those we've left behind. We only notice it when someone disappears on us.

So it can be touchy, this leaving others behind us, doing it well.

None of us wants to hurt anyone's feelings. Some of us can't walk away from a conversation until we're sure we haven't upset anyone. We can't terminate a conversation!

My tribe is particularly neurotic this way. Saying goodbye at a party takes two hours, seriously. Maybe this is a universal, for sure you don't have to be Jewish to worry about hurting peoples' feelings. As you turn to leave the party you can hear, in your head, the accusatory thinking. . . She didn't even say goodbye!

Long way around to talk about termination in therapy.
It symbolizes the death of an important relationship.
So we have to ask the question: Can a relationship really die?

We know our memories are buried in the hippocampus of our brains, probably wrapped in cozy blankets, stuffed into crowded, but air conditioned storage units. We pay by the year. If the memories are there, tucked in a tiny address in our brains, can a relationship, a metaphysical bundle of memories, really die?

They're all in our heads, somewhere, these relationships.

We used to say in family therapy, that there are invisible rubber bands around relationships, that it doesn’t matter what we call them-- married, divorced, separated. It is the relationship that defines the couple. And if they haven’t got a decent rubber band around that, if they don’t feel intimately connected, then guess what? They are already separated, even in a committed, married relationship, they may even be emotionally divorced.

The relationship between the therapist and her patient is also a metaphysical, cognitive entity, also bound by a rubber band. It can be very close, actually, intimate in some ways. But it isn’t marriage. The commitment of therapy is to treatment goals and objectives. It is the work we're committed to, and the intimacy is work intimacy, with no promise of ever-lasting, never-ending love. When the work is done, it is time to pack up our skill sets and go home. The imaginary rubber band becomes very thin, very, very large. You're gone, but not forgotten.

That’s the ultimate message the therapist has to convey to the patient in the process of letting go.
You are unforgettable. Your story is unique and you are amazing. I have learned from you. I’ll miss you, and if you need to come back, just give a shout. Thank you for trusting me, for sharing with me. I hope it helped, our time together.
They used to teach an entire course on termination, thirty years ago, in graduate schools, but I don't remember hearing this, that it is the therapist's obligation to convey these things to the patient, the meaning of the relationship.

What we do learn is that every one of us has or will have so many cut-offs in our lives, so many disappointments in relationships, so many deaths, both real and imagined, that a professional should be the last person to add to that class of aggravation.

Leave people miserable about the termination, unsatisfied, and unfulfilled, and they’ll bad talk you for years. I think that’s how they put it at the University of Illinois. They may even sue you.

And we can’t let that happen.

But you can’t please everyone all of the time, can you? And sometimes a therapist knows that a patient needs something more, someone else. It’s not easy sometimes to hear
We're not meeting your goals, and that's not good; it’s time for you to move on. You’re not getting better under my watch.
We make this call, by the way, not the patient. If we believe this to be true, then we have to insist upon another opinion, at the fatal six month mark, at least social workers do.
Am I helping this person? Should I get a consult? Should I punt?
We have to think this way. If we feel that punting will be detrimental, we need to get a consult, discuss the case with someone else, get a fresh opinion. And our consultant might say, punt. Each time I've done this, by the way, referred out, it has always been a positive thing to do. People need permission to move on, and we have to give it to them.

Sometimes we know that we're just exhausted, or we have exhausted our bag of tricks, and we're sure that a new perspective has to be better for the patient than to rehash the same old themes every week. Easing this human, our patient, down gently, feels next to impossible at first, especially if he or she has learned a certain amount of dependency in the therapy. First you crawl, then you walk, but a good mama wants her kid up and running, exercising.

The booby prize of therapy, surely, is a very quiet voice in the head, one that directs emotional wellness, fights off panic, and keeps you rational.

Up and running, exercising in the playground, no longer looking back, you hear, "Been nice to know ya'! Drop me a line!"

Because in this virtual world of ours, termination might just be a thing of the past.

therapydoc

*A complete exaggeration about FD to embellish the post. He does keep up with a few friends and some of his hundreds of cousins, and he never misses a barbecue.

** If you're my kid, and you're reading too much into this, CUT IT OUT! (cut it out is American English slang for Please stop! I assume everyone knows by now the meaning of chuzpah. (Let me know if you don't.)

***See Cat's post (I fired my first sponsor) about changing sponsors, one that prompted me to write Changing Sponsors, Changing Therapists on the Second Road