Hungry, Hungry HIPAA (in which I exaggerate for effect)

How did this become the quintessential interaction of my trade?

brrring brrrring*

Person: Well, hello. I am the person you have made up to recreate your iconically frustrating conversation.

Me: Oh hey thanks for that.

Person: No prob. Shall we get on with this?

Me: Sure, yeah. So aright: my name is Franklin Smearcase and I'm calling from The Society for the Righting of As Many Wrongs as Possible. I'm working with the attorney for Paradigmatic Client.

Person: [this is actually more or less what she said] Wait wait wait I have to stop you. I can't even talk about this person, who I may or may not have seen, unless you have a signed...

Me: YeahyeahyeahIknowIknow. Just...I know you can't even acknowledge that you might know the name, but I also have progress notes you wrote about him so...

Person: [Silence. Perhaps she is sharing an emphatic shrug with me, a shrug of "I fucking give up" over the way that worthy ideals get legislated into straightjackety impossibilities in the interest of Nothing Ever Going Wrong Again. Perhaps she is wanting to shake me. Perhaps she is juggling. On the phone, nobody knows you're juggling.]

Me: How about we try this: Just give me a fax number and I'll send you a HIPAA-compliant release for this guy who, oh, just to indulge a random fantasy, for all we know might one time have been seen for ongoing substance abuse treatment by someone who is you. I mean, it's a small world.

Person: Peach of a world. A true little corker.

[And then she gives me the number with which I can fail to fax her the release for Ostensible Erstwhile Client (né Paradigmatic Client) when some other shit distracts me.]

click

*I wonder if The Youth get all WTF about reference to telephones making bell-like sounds and if maybe in not all that long when we are miming the beginning of a phone conversation we will have to sing the awful little Verizon song or something.

I mean...

(Upon review, "readership" sounds grandiose. "Wherever shall I begin building my fan base?" In the blogosphere, readership is reciprocal, generally. What I mean is something more like a community, only whereas "readership" sounds grandiose, "community" sounds...well hey, as long as I'm going on way too long for a freestanding parenthetical: do you find that any time someone has a beef with social work they mention a particular song? Usually prefaced by "sit around singing [X]"? Ok I won't attempt to be mysterious where no mystery can really be found. The song is "Kumbaya." And one of those social work skills they never mention in class, like not flinching when someone tells you something horrible that happened to them because it is not helpful or conducive to further openness is not smacking the shit out of people when they mention "Kumbaya" as if to sum up your entire profession. Or not coming up with sarcastic song references to their profession, which is hard anyway. TPSAII: "community" is a bit far down the road toward "Kumbaya" for one's comfort. So let's just say: I'm figuring out if I can/want to be read much at all. Or if I'm just blogging into the void and for the entertainment of a few patient friends. Shall we close these poor overburdened parentheses now? I think we shall.)

Me vs. the Tea Party vs. Me again

I keep writing half a post and leaving it to languish in the realm of edit. Hard to figure quite what to write now while I see if I can/want to whip up anything resembling a readership.

Here's this though, because it's been bothering me. I just saw that a friend had joined a group on facebook called "I am American and I would rather live with Immigrants than Racist Assholes." Well, me too, obvs. But...this tone of discourse. It's gotta go.

I mean, listen, I get it. A friend from high school added me on facebook and turned out to be a teabagger and I was really hostile and made it clear I think his political party is a ship of fairly dangerous fools.

But here's the thing. Unless the next step in your plan involves violence, it doesn't make any sense to reduce your adversary to a monolith of wrongness and leave it at that. No matter how much you hate what they are saying, you have to consider it motivated irrationality and try to get your head around it a little.

I watch this happen everywhere, and I frequently participate. From the New Yorker* and its cringe-inducing condescension toward/baiting of Red State anything to meaningless internet wank like RaceFail to plenty of other ways and places people butt heads, I just don't think this is a good idea.

It feels good to call someone stupid if they have offended you. For a few months after Prop 8 in California, I had a few venomous sentences in my head that I day-dreamed about rattling off to the next pair of Mormon missionaries I saw in my neighborhood. It feels good because it's a tiny speck of revenge, and it feels good because it establishes your solidarity with the other folks on your side.

It just probably isn't worth it. My single new year's resolution for this year was "1) Be less of an asshole about religion." It's hard sometimes because I think religion is incredibly destructive. But I realized I was starting to sound like a crazy person. Well, or to sound like the people who provoke my (tiny, futile) rage.

I think we're not this bad. I think the fear we have is of unilateral disarmament. Stop attacking the tea party and maybe they'll win and we'll all have to celebrate Ayn Rand's birthday by laughing at a poor person. This is maybe our semi-conscious suspicion, our worst case scenario.

But the thing is, what we're doing now isn't working either.


*The New Yorker is basically my religion, but.

RIP Alice Miller

The Times has published this obituary for psychoanalist Alice Miller. I've had her books recommended to me over the years but know her primarily as an interesting minor character in Janet Malcolm's In the Freud Archives (possibly the most gripping and insightful book about psychoanalysis I've read.) As I remember it, Dr. Miller comes off in that volume as sympathetic and level-headed. I'd say this is a good nudge to read her books, but it's so hard to follow through with that kind of thing in my somewhat post-clinical life. Anyway, it seemed worth noting.

Further adventures of FPS in Fuckaway

It's tough to remember whether there was a time when I thought I could make a go of it at the Fuckaway Center. I can sense doom at twenty paces, usually, and the writing required an especially large wall to fit on.

Beyond the massive supervision fail, there were a dozen reasons to hate being out there, and the only reason to stay (at the time, better job market) was that it seemed like my path to being a therapist. But, yeah, much to dislike. Coworkers who found the place utterly normal and my evident distress about it a little bit crazy, that was one thing that should have told me to get out. You can go around saying "isn't this place terrible?" but between the possible objective reality that the place isn't terrible and you are just Doing It Wrong and the possible objective reality that they are all nuts who can't see the disasters around them, well, there ain't much twain.

I should say more about why it felt like a madhouse (ok, stupid choice of words considering it was in some sense functionally a madhouse.) I should say more about why it felt like everything there was profoundly bad. Because the truth is, clinics like that might well feel a bit like an emergency room. The populations that have to rely on interns and people straight out of grad school for their mental health care because that's what Medicaid will pay for are not easy to take care of.

Often the baseline of "things going wrong vs. things going ok" is already pretty low, and in Rockaway in particular, well, the people who came through that door were very rarely there to discuss how nervous they were about their retirement funds. In all but the most floridly psychotic clients (and maybe there, too) there was content that you could dig into--and I mean this less to reduce clients to their interestingness-level to a pretentious young therapist, I hope, than to talk about the difficulties and possible inefficacies of talk therapy across some serious barriers to understanding, many of which could be navigated with good superivison but see above. Or below. Stupid blog format vs. referential conventions.

But wait, this is actually the point. I had a lot of clients I didn't know what the fuck to do with, and nobody was giving me the least suggestion of what the fuck to do with them. This could have been because they assumed I was better prepared for this work than I was. This could have been because they had little idea more than I did, were all inured to How Things Are and just saw the people, let them sit there in their offices while they wrote billable notes, and called it a day. There could be other explanations.

I'll never know. I do know I had serious misgivings about asking for help, not just because Murgatroid seemed, and I won't try to paint myself as less than judgmental here, just not to be very smart. Also because of how things were discussed higher up.

Aunt Slappy did something I read as very supportive early on, and then came to have enormous misgivings about. So, let's take for example the kid clients I had.

Backing up, to the point of incoherence, I had always hoped not to work with kids because I'm awful with them, but in a community mental health setting, you get a ton of kid clients no matter what. It's a socoieconomic thing I probably don't have the perspective to dissect, but to me it always looked like people with kids they didn't particularly like, but also kids who lived in a terrible environment and were hard to manage by any standard, bringing them in and saying "fix him. Or just take him off my hands for an hour."

I was hopeless with these kids. I can't imagine I did a damn thing for them. I talked to them in the useless, annoying tone of a person who doesn't know how to talk to kids. In some cases, I spent the hour just trying to keep them from hurting themselves on sharp desk edges because they were so hyperactive, or saying "no you can't have that" when they picked up thing after thing and said "I can have this?"

It's tiring having that kind of privation bounced off you and thinking about where need that ceaseless comes from. It's tiring and distressing trying to make some tiny connection with someone you have no idea how to connect with. Sometimes you take these frustrations out by getting mad at the parents, who in many cases really do seem like walking horrors.**

I was too busy talking to Murgatroid about my charts to ask about any of this (which is its own story) but sometimes I'd talk to Slappy, and she would be, as I started to say, apparently supportive. She'd take my side anyway. She'd fume at the parents. And then eventually it occurred to me that I was standing in the office of my clinic supervisor listening to her say about some kid's mother "I know that woman from way back. She's a piece of shit."

Someone once said to me "Oh, I've had my analysis. I don't have countertransferences anymore." I didn't bother to express my skepticism because it was a friend and someone who indeed reacts fairly to many things and seems to have benefited from analysis. TPSAII*: all people's training and all their advancement within the field sometimes means very little or nothing about how they react to Things That Happen. I was working in a place mean to help people, ruled with a tanned leather talon by someone who referred to these people or their families, frequently, without any encouragement to stop and think about this stuff, as garbage.

This was not a place I needed to be.

Right, yeah, I'm going to keep going....


*The point, such as it is. I have decided this is probably something I should just abbreviate.

**Hey, sorry. The last entry was funnier, right?

The Deep End

Part 1,
because this is obviously going to run long so maybe it's best to chop it up. By the way, yeah, I'm kind of feeling out what the hell to write about because currently not many people read this, so I can play around. That may remain true, of course. I had a piece of luck at my old blog, a link from someone with a metrick fuckton of readers. This may turn out to be more of a Marsha Brady writing in her diary type of situation. And if that's true, I have all the time in the world to futz around with content.

With that out of the way...

I was thinking earlier about my first job out of school, and I've told people about it about a billion times but never really written out the story. So if that sounds at all interesting, stick around. It is, oh, pretty much a tale of woe in which things go not so very well. Read on if you are a Schadenfreudian. This is Schadenfreude with consent.

2004. I had completed my degree in a town that was not the town I wanted to live and work in. Clampett-like, I loaded up the truck and moved not so much to Beverly but to Manhattan with a sublet and no job. Somehow this did not strike me as especially foolish.

Went on a few interviews for jobs that would have been the death of me. I was in over my head one way or another, never did a stitch of social work before starting my MSW program and had no idea what I was doing. In some ways this has not changed, but I fake it a lot better. One interview was in Far Rockaway, working in the dilapidated high rises by the beach that are full of elderly Russians and people from the former republics, the ones who are not doing nearly well enough to live in Sheepshead Bay, I suppose. I would have had an enormous caseload and really my Russian was in lousy shape by then. I think the woman interviewing me took one look and knew I'd be a disaster.

Weeks pass. I'm wondering if I'm going to have to leave New York. I get another call out to Far Rockaway, and I go out for the interview, and it's immediately clear that it's a good match, even though of course this turns out to be untrue on a scale that is tragicomic, possibly epic. But I do have experience as a therapist in community mental health. I speak Russian (though they determine this by having me exchange exactly two sentences with a native speaker.) They are openly very enthusiastic about me, and....they seem surprised that I want to work there. Which is never a good sign.

If you want to picture them, the two people interviewing me are in their late 40's, tanned to a crisp, blonde in a way that nature may or may not have intended but Ashkenazic DNA pretty much forecloses, and have intense Long Island accents. The director, who I'll call Aunt Slappy if I have occasion to speak of her again, will later pronounce "poignant" as it looks in some conversation about Billy Crystal's doubtless utterly poighnant Broadway show*, and being a word snob, I'll say to myself "I really should have known about this one."

They introduce me to my supervisor who I'm going to call Murgatroid. She has a look of blank, stative panic in her eyes. "Working with Murgatroid," I am told by Aunt Slappy, "is a great clinical opportunity."

I get my first client. I couldn't tell you her name or her story if I wanted to. We'll briefly call her Hellacia because she's not in this story long, and if you're noting a dread of my clients in this name that doesn't speak well of my ability to treat them, you're noting right. Let's all sit around the fire and read "Hate & the Countertransference" (sort of like "Sex & the City" but no, not really) aloud, the fire composed of drafts of the conference paper I was going to write on difficult clients and what helps us do something for them. Not on that list: supervisors like Murgatroid. I had 11th grade English. That's called "foreshadowing."

What I remember about Hellacia is that I was told right away she was infamous at the clinic, had been there for years, had a chart you could use to boost a small child at the dinner table and Borderline Personality Disorder, which is a salient diagnosis but also something a clinician hangs around the neck of anyone that pushes his/her buttons.

The session is totally fine. She makes some overquick cathexes, tells me I remind her of her brother or something, and we're done. Except five minutes later Murgatroid comes in and says my client has completely decompensated in the waiting room and is screaming at the receptionist.

I've been a professional for one hour. I have no pride to swallow. I skip any hedging and say to Murgatroid, my supervisor, my holding environment, my safety net, "what should I say to her?" Murgatroid looks at me with the same blank panic I saw during my interview and will see for the next nine months of my life and says "I don't know what to say to her!" and basically walks off.

The universe takes pity and by the time I get out there, the client has not only calmed down but left. Just the same, I'm a dead man. I am suddenly aware that I am fucked. Murgatroid will turn out to be only one of my problems, but my basic impression is correct. The person who has been charged with managing my transition from student to professional is an addled, not particularly bright person who appears to have been shattered by years at this clinic. We will have a total of maybe 45 minutes discussing anything about my clients over my 10 months at the clinic**. The rest will be about their charts, because that kind of clinic exists not for the sake of clients, but for that of charts.

About the clinic itself, I should mention that the general air of the place was something between an emergency room and central booking. It's the nature of the neighborhood, in part--socioeconomically at the bottom of the barrel, and also through some accident or "accident" of the deinstitutionalization process, it's where a ton of group homes ended up so they wouldn't have to look at them in patchily wealthier western Nassau County.

A lot of people who want to be therapists have the same naive fantasy I had going in: working with the "worried well," on their depression/anxiety/other manageable problem. That's what happens on a tv show, maybe. This was what actually happens, in concentrated form. Clients who don't show. Clients who have to be hospitalized. Clients who are there for their meds and can't possibly fill ten minutes, not to speak of an hour, with introspection or even perhaps conversation...

Um this is not really a cliffhanger here but to be continued...

*Uh, this is maybe so far off-topic as to be of no interest, but the Billy Crystal thing is what we would call diagnostic in the biz. The people I worked with live in Nassau County and treat New York City with a kind of Victorian dread. It seems to me this is not exactly healthy for social workers. They express alarm that I'm taking the A train home, not because I have to catch it at the Far Rockaway station which genuinely was worrisome at the time, but because I'll be going through Bedford Stuyvesant. In truth I 1) am going under it, and 2) looked at an apartment I couldn't afford there, so. Anyway, I find myself wondering why they don't move to another part of the country, but I guess the dread is a giant, overwhelming garnish to a tiny sundae of delight, because all of them maybe once a year will go in and see a Broadway show or something. I think of them when Carmela takes Meadow to the Plaza for tea on The Sopranos. It's something I'll never understand, as someone who worked pretty hard to live in this urban hell. I can understand getting tired of it, but I can't understand never being a little in love with it, at least.

**I eventually start referring to Far Rockaway as Far the Fuckaway and the clinic as the Fuckaway Center for the Farblondjet or something like that. I'll just stick with that.

Vorshtein

I started to post about my first job, but it started getting long and maybe a little like a therapy session. I'm a little bit interested in people's stories of professional disaster, because I had a few, and tend to say to people "there are a lot of bad social work jobs out there" based on not that much evidence, but I can't help but think it's true. It might be interesting to post about later if there turns out to be much traffic around here. I saw a few hits from here and there already, which is gratifying.

There are a few things hanging out in my brain that I want to talk about, but otherwise it may be wise just to write about the things that happen day to day here. I'm not exactly writing this to get out my own frustrations or to edify anyone. I guess I like the potential sense of community that blogs offer, even if it's a fragile sort of community.

Today was slow, and that's a topic in itself, though I'm not sure how to go at it. What I'm interested in is that I have a lot of down time, and I need a lot of downtime, and I've always assumed everyone does. And in the job I started to type about, for instance, there was this immense effort at putting on a pageant of everyone being busy every moment. How anyone could survive that I don't know, or why they'd want to.

Look the value of work is that it gets something done that needs done. Somehow this has been turned on its side in American culture. Think about this in the most basic way: Suppose you were completely done with what you have to do today, and you said to your boss "I'd like to go home now." Your boss would of course assume you were speaking hypothetically, and would say "sweet fancy Moses, so would I!" You would not go home.

The particular social work side of this is how it's been institutionalized, or this is my hunch as I sit here and type with my ass. I mean not literally. That's like "talking out your ass," an expression I sometimes use and then think I'm making it up and think I sound vulgar/crazy and remind myself next time to say "talking out my sleeve" which I'm not sure exists either but at least it doesn't give people nightmares.

Where was I? Well, think about audits, the things that define work in a clinic. One could only believe these occur for the benefit of clients* if one were being paid to believe this. They are there to make sure that social workers are not playing FreeCell or writing blogs or napping under the desk (what, you don't?) during the last fifteen minutes of sessions. They are there to make sure not only are you doing something that can make for a convincing progress note for most of the session, but that you are using the end of that session to write that convincing progress note. I really do think this is true.

Like all other exercises of authority, what they mostly do is inspire methods of subversion. I don't even know if they still do this, but quarterly progress reports--themselves an abomination--used to call for, what was it called, a performance review or some piece of meaningless jargon like that, might as well just call it a vorshtein, and they had to have this long sentence at the end of them that was a kind of formulaic language beyond all reason, and so eventually we all just learned what was supposed to be there, got very adept at writing vorshteins quickly and writing one individualizing detail at the end, and getting an LCSW to sign off, which they did without reading because nobody had any illusion that there was a point to this.

Things like this, if you squint at them right, they are important roots of societal problems. Because they mean that the people who will stay in those jobs are people who are okay with writing vorshteins rather than doing anything meaningful. I'd rather have someone lazy in a job than someone who could spend ten years writing vorshteins. Hell, maybe those people like them. Maybe they write them for fun, or do cross-stitch vorshteins.

This is how the unfortunately aggregated and decentralized villain that is, I guess, the imaginary will of heartless capitalism makes sure people who don't deserve anything never get a shot at having it. That sentence is terrible, but maybe you know what I mean? I'll try this again: the structure of our working life suggests that someone out there doesn't want us to do any good. It's like the argument of intelligent design, inverted: things could not have gone this wrong without a decision that they should be so. And yet, probably not a constructive thing to imagine.

Probably this is all simplistic and muddled to people with a bigger mind for big systemic grokking of things than I have, but it feels worth bumbling my way through.

*or consumers or customers or cupcakes or whatever term we are now supposed to use; again, not an issue of importance to the cupcakes themselves.