Dispatch No. 8

Site Design 2.0!, The Challenges of "Value-Based" Reimbursement

Welcome to Holbemn 2.0! Much thanks to K.Q. Dreger of Audacious Fox for the site design and for coaching me through this blogging experience. If you haven’t read AF before, pay Dreger a visit and treat yourself to the one of the best privately written columns on the internet. Both in person and on the web, Dreger is one of the sharpest and most thoughtful people I’ve come across, and best of all, he writes with the intent of being respectful of your time. I could stand to take more than one leaf out of his book…

On Mondays I come into the office, and attempt to be here at least 15 minutes before anything I’ve scheduled that morning. I sit down and on a blank 8.5”x11” sheet of paper, meticulously folded in half to be able to flip like a book, I copy the neglected, strike-through-less items from last week’s to-do list.

As I go through this process, I cope with pangs of guilt for calls I haven’t made, documents and charts which have gone unreviewed, dozens of housekeeping tasks that will likely never affect client care in any meaningful or outcome modifying way.

Herein lies my deeper frustration. A significant portion of my down-time is spent doing things which have no direct impact on the well-being of my clients.

But there are also the items which have travelled from list to list over the course of months, as opposed to a week or two. These are the tasks and pursuits that would enable me to be a better clinician: Trainings to look into and receive, books to read, ideas and proposals to develop for new services to offer our clients.

But sadly, those fall to the background of my day-to-day, and I find myself beginning each week on a frustrating note as I compile a large list of menial tasks.

Unfortunately these administrative tasks are multiplying as behavioral health organizations face increasing pressure to conform to insurance companies’ push to integrate “Value-Based Reimbursement,” an initiative mandated by the Affordable Care Act. Insurers, including Medicaid and Medicare, are beginning to require measurable results and outcomes documented on a regular basis to prove that care is working to reduce impairment. If progress is not being made, they won’t pay after a certain point. They will cease to offer their reimbursement to those providers and send the client to another agency or provider.

This theoretically makes complete sense. Healthcare providers should be accountable, data-driven, and intentional in their treatment, not simply seeing clients for years on end with no significant progress.

But therapy doesn’t always work on a schedule, and to ascribe a certain expected timeline to someone’s healing process seems to me to be just one more way that capitalism requires systems to place a dollar value on truly unquantifiable processes. For an insurance provider to hypothetically say in essence that under a provider’s care a client isn’t healing from a trauma quickly enough or demonstrating enough improvement in their ability to cope with an ongoing stressor such as an abusive spouse or family member seems to me to be cruel and uncaring toward the realities of the field.

Problems in living and the subsequent healing that people seek through therapy can hardly be quantified as one would a patient’s T-cell count in the course of HIV treatment. So to say that one’s response to treatment isn’t sufficient, and that the response will be to break a well-forged therapeutic relationship and force one to start over with another provider in the name of the bottom line strikes me as misguided and ignorant.

Meta-analyses of psychotherapy research routinely demonstrate that a client’s connection with the therapist is the number one determining factor for healing and growth to occur, surpassing therapeutic modality and all manner of demographic factors in influence. I believe this to be true and though my experience is anecdotal, I’ve personally rarely found much success in clients who I have not felt connected with. In fact, many times it takes months, or even greater than a year for a client to determine that I’m truly trustworthy enough for them to reveal the true issue that’s going on.

For insurance companies to place a required timeline on healing while ignoring the largest factors which drive it is at best, a misguided attempt at improving care outcomes, and at worst a shallow and transparent push for cost reduction.

Assuming the former and the best intentions of the insurers and policy-writers, it highlights how incredibly difficult it is to create and implement healthcare policy, especially for a system as fragmented as ours is in America. The system isn’t built in a way that values therapy for the hybrid of art and science that it is, and that it instead drives it to look more like a system to be streamlined, made more efficient, optimized. And if the internet and other “optimized systems” have taught us anything, it’s hard to preserve the human at the center of the process when you reduce them to data points.

I’ll get off of my soapbox now, but these are truly my thoughts as I write down the meticulous memos, assessment scores, and background documentation that I need to do to prove my efficacy as a counselor. I’ll continue to comment on this sort of thing from time to time, and hopefully provide some useful perspective from the behavioral health front lines.

As for my plan, I’ll be fighting for my clients however necessary. I’ll comply, rebel, do whatever I have to to protect the therapy that I know delivers results, however difficult and unquantifiable they may be.

The fight is at the top of my to-do list.

Dispatch No. 7

Friday Quiet, The Past, More on Masculinity's Perils

Friday mornings are my favorites, for all of the obvious reasons and others. For one, Fridays are a half-day for me, making up for the evening hours I add to my schedule earlier in the week. Having an afternoon off to run errands, hit the barbershop, and kick off my weekend early is pretty stellar. Some of my favorite clients come on Friday, and it’s nice to wrap up the week on a positive note, celebrating the hard work they put in and successes they reap.

Less counselors work on Friday which means less clients and an overall quieter atmosphere. It’s usually pretty quiet, but I’m highly prone to distraction, and it’s nice to be able to leave my door open and still get some work done. Today the sun is peaking through the clouds here and there and its effects coupled with a nice quiet office is perfect for reflection.

So far in my therapy with others I’ve been operating from several assumptions about people and their potential for change at any given time, but I’ve come to realize recently that I’ve been overlooking the role of the past and how it keeps people stuck.

I have always made it a point to treat my clients as if they can go out tomorrow or the next day and apply for a job as a CEO or their dream job. I attempt through my actions, interventions, and my verbiage to sell them on the concept that they are wildly capable of positive change and accomplishments they can’t even imagine. I do this because I believe these ideas about human potential to be true.

That being said, I believe that I have failed to fully recognize and contend with the role of the past in keeping people stuck where they are. In focusing largely on where I believe people can go, I worry that I haven’t always provided the room or the direction for my clients to deal with their pasts and process them.

I think this has been my general style of counseling for a few reasons. Foremost is my own personal way of moving through life. I’m not a very past-focused person and tend to be much more present and future-oriented. I’m positive this is because I’ve led a very privileged life and haven’t been subjected to trauma or even major life disappointments that tend to root oneself in the past. And like any bias, I’m sure that my own personal experience and lack of hinderance for changing my own circumstances leads me to believe it should be that simple for others as well.

While I’m not especially proud of my own experience being a causal factor in this oversight, I think it has some benefits also. I know for a fact that some of my clients have been helped by my dedication to treating them as they could be, not how they are now or how they have been. In essence, I make a point not to treat my clients as sick people, but instead as capable and impressive, worthy of celebration. I don’t intend to change this aspect of my work and will maintain this overall attitude, but I plan to find new ways to engage the past with clients so that there is a bigger space in our shared work for it.

I also have to consider that my bias is likely influenced a great deal due to the fact that a large portion of my work is with boys and young men. As I mentioned in my last dispatch, excavating and mining the past for roots of ongoing issues and symptoms in counseling is not exactly most men’s idea of a good time. And in my efforts to make the counseling process amenable and tolerable for them, I don’t do a lot of prying in my sessions with them, lest I scare them off.

Through recent experiences and minor “breakthroughs” I’ve had over the past week or two, I’m finding that though men talk about it less, the past still plays a big role in keeping them stuck also, and just because it’s not put out on the table as quickly or willingly, it still needs to be dealt with for progress to begin.

Speaking of men, the NYT just published a great article on the American Psychological Association’s new recommendations on the dangers of “Traditional Masculinity” and its impact on males. I think the Times did a wonderful job summarizing and reflecting on the new recommendations, and in doing so gave better language than I find myself able to regarding the pitfalls of “manly-man” expectations for our youth.

As always, this practice of mine continues to grow and evolve, and I hope that I am able to better serve my clients as a result of this period of reflection.

I make it a point each week as I close my laptop for the last time on Friday afternoon to take in the fact that all of my clients are out in the world at this very moment. I gain a lot of joy and excitement thinking about them out in the world, living their lives, hopefully better from our work. Each one is going about their Friday, staring into the face of a weekend, just like I am. Perhaps with excitement and possibly with dread. Just like me, they have a future of infinite possibility laying ahead of them with unforeseeable achievements, experiences, and challenges to take on.

But they also have a past, and I will do more to attend to it in our time together. They are deserving of that attention and in need of it, whether consciously or not.

Dispatch No. 6

The New Year, Women for 2019 and Beyond

Happy New Year Holbemnites!

Because it’s almost a new year and because my work and clients are always in the process of reinvention, This is the first dispatch to be handwritten then typed for your digital pleasure. Well, because of that and the fact that I am 12 years old and just got my first Fisher Space Pen, which is a delight to write with.

It is the end of winter break and I am one member of a veritable skeleton crew here at the office working the week between Christmas and New Year’s Eve. The quiet has been nice to get somewhat organized and to tackle some tasks I’ve neglected. My desk for instance has become cluttered with several piles of paper, some inches thick. They begged to be placed into folders in an appropriate drawer, and they finally received their wish. Organization is not my strong suit.

In reflecting over several themes of the past week, I’ve been finding it more and more interesting which clients of mine have a curiosity with my job. Only a few ask me questions about what it’s like to be a therapist, and though I don’t point them to these collections of writings, I wonder what it is that makes them so curious.

The question about what other careers are like is one that I ask myself all the time as I go about my day to day. What is it like to be a mechanic, a lawyer, a handyman? I think it’s a valuable trait to be curious about others’ experiences of the world, and I like learning about which clients wonder these things as well. Most of all, I suppose I’m curious about which of my clients have grown comfortable enough with me to ask.

Speaking of which, I’m so proud of my clients. Looking back on the year, there have been some really cool breakthroughs that have really surprised me and left me in awe of the resilience of the human spirit. That’s a huge phrase to throw out there, I know, but if this were a blog about sharing clients’ testimonies and experiences, you’d agree wholeheartedly.

This year I’ve become especially enamored with the power of my women clients to make enormous personal change and sacrifice to improve things for themselves and their families. From women who make changes to lead a more empowered life, to mothers’ sacrificing time and opportunity for their children, to grandmothers stepping in for grandchildren and raising them to provide much needed stability, witnessing these stories played out has made me grow even more impressed with the female power than I was prior to entering this field.

And while I’m sure I cannot articulate this well enough, I really feel like we as a human race would be in a more advanced place if women had more say in our decision-making. I’ve been exposed to women who demonstrate resilience, courage, and extraordinary capability to make difficult decisions in the face of emotionally and logistically complex situations. Routinely, I’ve seen this play out and I believe that women’s ability to juggle the emotional and the pragmatic is exactly what we need to take us to a better place. Perhaps I’m biased due to white male guilt, and/or I’m sufficiently horrified by our current political state, but I feel that women’s dual-skill set of both emotional and intellectual intelligence is a set of skills we don’t have near enough of societally.

That being said, I also weep for the opportunities we deprive young men of through our narrow societal expectations. Too much emphasis of toughness and burying emotions over the development and expression of the so-called “soft-virtues” of empathy and kindness has led to the polarization in our culture which has reduced our social progress in the hands of men to a mere trickle. Much of my work with men and boys returned time and again to reversing years of emotions repressed to meet and serve these expectations.

I realize I speak broadly and of topics which are far more complex than I can possibly view from my office, but I believe that the things I have witnessed as a therapist can be extrapolated to represent our social status on a larger scale. In the particular we find the general. In particular there are several clients of mine who I would send to congress or the white house today, I’ve become so convinced of their capabilities.

In my clinical practice and in my personal life I want to continue to grow and seek opportunity to empower my women of all ages, encouraging and reinforcing the immense capability inside of them. It’s through them that I see real world change occurring, and it’s in them that I find so much hope.

Holbemn Recommends No. 1

Esther Perel, Mandolin Orange, Sounds of the Winter

Happy Holidays!

With this installment of Dispatches on Therapy, I’m adding a new form of post, one that may feel even looser, (they thought it couldn’t be done). Though I am a therapist, I still find myself spending a highly unmindful amount of time engaging with my phone and consuming media of all sorts. And while I’m trying to curb that, I figure I might as well turn some of my browsing into something more… intentional.

Hence, Holbemn Recommends! I want to take the time here and there to share a few of my favorite things from art to music to interviews and journalism which speak into and inform my therapy practice, or fuel me more personally and artistically. I hope you (mindfully) enjoy them and find some of the same inspiration that I have.

Let’s kick this off.

The New Yorker - Love Is Not a State of Permanent Enthusiasm: An Interview with Esther Perel

If you’ve read any of my writing, you know that therapy still holds a lot of mystery to me, particularly in regard to how other people practice therapy. Nearly everything we do is behind closed doors, so when I get a peek behind the curtain into someone else’s practice, there’s a huge validation for all of the frustration and unknowingness that I feel about my own practice.

So when I stumbled upon This New Yorker interview with marriage therapist and podcast host, Esther Perel, I dove in immediately. Esther and this interview are wonderful and filled with wisdom. If you have time, absolutely listen to the clips from her podcast which invites the listener inside real-life couples therapy sessions. My favorite snippet from the interview: “We have gone up the Maslow ladder of needs, and now we are bringing our need for self-actualization to the marriage. We keep wanting more. We are asking from one person what once an entire village used to provide.

Mandolin Orange - Live at the WGBH Fraser Performance Studio

I love Christmas music a great deal, but even I find myself in need of a carol reprieve partway through the holiday season. This intimate and wonderfully engineered performance by Mandolin Orange fits the bill perfectly. I’ve had it on repeat throughout my documentation hours, and find myself perpetually distracted in the best way by Andrew Marlin and Emily Frantz’s virtuosity. If you aren’t familiar with them already, you won’t find a better or more proper introduction to the best Americana duo around.

I’ll close my first Holbemn Recommends with a poem I came across by Walt Whitman.

Sounds of the Winter - Walt Whitman


Sounds of the winter too,
Sunshine upon the mountains—many a distant strain
From cheery railroad train—from nearer field, barn, house
The whispering air—even the mute crops, garner’d apples, corn,
Children’s and women’s tones—rhythm of many a farmer and of flail,
And old man’s garrulous lips among the rest, Think not we give out yet,
Forth from these snowy hairs we keep up yet the lilt.

Whitman’s poem is beautiful, of optimal length, and distant to the winter rhythms I experience personally. I hardly find myself surrounded with the sort of outdoors work and quaint sounds which form the basis for Whitman’s scene. My own soundscape is formed of clients’ diverse voices, gentle keyboard clacking, and the whisper of white-noise machines (damn them.)

But despite my more urban, modern setting, the old man’s words propel me forward still as I go about my work during this Christmas season, “Think not we give out yet, Forth from these snowy hairs we keep up yet the lilt.”

Dispatch No. 5

Hunger, Discernment

It’s mid-afternoon on Thursday, and I’m missing the bloated-full feeling I had exactly one week ago around the Thanksgiving feast-table. Of course I forgot my lunch in the fridge this morning, so the hunger pangs I’m experiencing are not helping things any or giving me motivation to get through my last few sessions.

It’s been an interesting week, though they all are in their own way. I had my fourth client of the same name enter a crisis period, joining the aforementioned three comrades in a deteriorated dangerous mental state. I truthfully didn’t even know I had that many clients of the same name, but they’re really grouping together now. I’d love for them to meet one another. I should start a group geared toward supporting them.

Over the past week, I’ve been making a concerted effort to pray more, and to be more spiritually focused before going into my work. I am working to reinstate my habit to make it a point to pray each morning that I would empty myself, get out of my way, so that the Lord can flow through me and speak through my actions and my words and how I make my clients feel. When I’m able to do this, I feel more present and I feel that I do a better job of discernment. Discernment in the sense that I feel I am better able to read the needs of my clients and, as I’ve mentioned before, move them toward a view of themselves that is closer to how God views them.

I’ve been struck by several cases over the past week where my clients relay things that have been said to them by close friends or loved ones that just strike me as unbelievably hurtful. I don’t think we recognize on a regular basis the impact of the things that we humans say to one another when enraged to the point where we disconnect from our frontal lobe, (the region of the brain responsible for forethought.)

I’m incredibly blessed to have been raised in a household almost entirely free of this sort of toxicity. Where it did exist, I was almost always the progenitor. That being said, these behaviors, often perpetrated by adults, against children or young adults is just mind-boggling. Bearing witness to it, whether in person or indirectly, has really shed some light for me on why people can end up spiritually and personally broken. The impact of hearing one’s own parent saying, “I don’t want him. Nobody wants him,” (real words spoken in my office in front of the “him” being referenced) is soul-crushing. Those words aren’t unheard, nor will they ever likely be forgotten.

I suppose the biggest takeaway for me personally, having heard firsthand of some truly awful experiences, is how much of a premium it puts on my everyday interactions with others. There are all sorts of videos and think pieces on this concept that you never know what someone else is going through, or has been through, and they couldn’t be more spot on. The impact of a warm and kind interaction with someone becomes life-giving in the context of such radically hurtful past experiences; I’ve heard so from clients who have been to some dark places.

I know personally that this is something I need to continue to work on. My adolescent self hasn’t fully worked itself out yet, and I could absolutely stand to improve my level of generosity and mindfulness in my interactions. To not just to be passively pleasant or tolerant (or tolerable for that matter), but to find drive to be actively generous with my words and actions.

These pieces always end with my own takeaways from things I learn from clients, and highlight why I find this job so fulfilling and life-giving. I really do believe that I get way more out of this than my clients. I’m constantly reminded through this field, as well as my spiritual and personal pursuits to back up my words with actions. To not do so would be an opportunity missed.

Dispatch No. 4

Frazzled, A Reset, Working from Rest

Friday, November 16th:

"Do not be afraid of work that has no end." Avat de Rabbi Natan

Scott Harrison shared this quote when he was interviewed on The Robcast with Rob Bell recently and it's become somewhat of a mantra for me, grounding me when things feel daunting or overwhelming or stuck. There's a lot of those feelings packed into this job.

This has been a strange week, in that I've taken my work home with me more than I intend to. Not in the, I'm doing notes when I should be spending time with my wife sense, but my clients are in my head more than usual. I'm finding myself worrying about cases and taking note of cases in which I perceive that I am stuck and not making progress. I write about this often, and I fear that it will be boring to read about. If it's boring, it's boring though, and I'm fine with that. I would prefer to be truthful and rather dull, than to come up with some artificial thread of narrative excitement to try to keep some sort of curb appeal to this.

Contributing to my weakened resolve to separate work from life are several clients of mine who have had crises of sorts over the past week, three of whom share the same first name. This coincidence has blown my mind. Across my relatively small caseload (compared to some agencies), I happen to have three clients whose mothers chose the same name, who all happen to be melting down and declining in their ability to cope as the November rain continues to fall. I don't know if there's any sort of meaning to be found there, but I can say with all certainty that it's just one more name my wife and I won't be considering when it comes time to have children. I mentioned this coincidence to the mother of one of my clients, the name being common enough for me to share without truly disclosing any client information, and she said that the trouble is absolutely in the name.

I was talking to a client recently who was venting about how frustrated she was that everyone around her kept apologizing for how sorry they felt that she was going through a health condition which was causing considerable discomfort. She said she hated being treated like a victim, and couldn't understand why others were responding this way. We reflected that people are made uncomfortable when they don't have control over a situation, and they respond in any way they can, often by apologizing. We apologize because we naturally want to demonstrate some sort of control over the situation. If we are not able to fix the situation itself, we offer to share emotion, to adopt and shoulder some of the pain.

Monday, November 19th:

Checking back in with this dispatch to finish writing it and man, it must have been a relaxing weekend, because I don't even connect with what I was writing this past week.

I got home Friday with more work to be done and upon opening my laptop, I promptly shut it and didn't return to it until this morning. It was an excellent decision. I think that time to destress and disconnect, along with the prospect of a wonderfully short week has me feeling quite a bit better.

Ready to celebrate Thanksgiving and stock up on good vibes for the next stretch.

I'm reminded of something my pastor shared in a sermon a while back. In reference to the creation story in Genesis, my pastor commented that it's significant that on man's first day on Earth, God deemed it a day of rest and focusing. We are to work from our rest, rather than rest from our work. While that's all well and good, it certainly adds to the poetic fantastical nature of the Genesis passage. The real world can be a little bit messier than that, but it's good wisdom on the whole. Sometimes it takes putting off some work and shutting the laptop to right the cycle, but I'm ready to get back on track.

Dispatch No. 3

When it Clicks, Celebration

Boy, this counseling thing is a real ride. Feeling particularly blessed and energized at the moment. There’s something about this job where when it’s good, it’s really good.

There’s this feeling I capture maybe once or twice a month. Sometimes after a session or a day of sessions with clients that go particularly well, I feel confidence and conviction that lets me know I’m making a difference and that I know what I’m doing. It feels so counter to the 98% of the job where I feel more like I did this morning as I fumbled around my house, putting on my boots and coat in the dark, stumbling out into the rain while my wife slept (dear Lord, that woman deserves this day off.)

But the feeling I have right now is a total high of sorts, when things click like this. I’ve never had a runner’s high, (only lows for me when I run,) but from what I’ve read, I imagine it feels sort of like that. There’s just a sense that I get when a client is progressing, and finding what we do in session useful in their lives that gets me feeling so energized, like I’m where I’m supposed to be.

Driving home yesterday I was listening to an episode of The Robcast with Rob Bell (a joyful man who loves goofy titles) and Fr. Richard Rohr when I was struck by a divinely revised job description of sorts. My job is to help others view themselves the way God sees them. Not inherently flawed, but inherently blessed and equipped to fulfill amazing things set aside for them. I believe that the feeling I am experiencing comes directly from having a sense that I achieved that in some way or other.

As I write this, the sun is coming out for the first time in days, and I can’t think of a more perfect celebration. I’m stretching out and it’s my intention to soak up both the sun and this feeling. May it carry me through the next stretch of fumbling and stumbling, and I pray my clients receive this joy as well.

Dispatch No. 2

Lunch Break, and C.S. Lewis on Undulation

It’s not a good sign for the week that I’m getting my days mixed up. It’s Tuesday of the week before I go on a week-long vacation, and in my head it’s already Wednesday. I’m a day ahead of myself and the omens keep piling up.

I have a half-hour before my next client, but their bus brought them here early. Normally I would be inclined to see them early, as I don’t feel like wasting anyone’s time. Today however, I’m in the middle of my lunch, and with my door slightly cracked, I can hear them out in the hallway making clicking noises and whistling at a low volume to get me to poke my head out of the door. It’s not like they’re even knocking. Even that would be preferable to being signaled at like some sort of caged chimp. I will see them at precisely their appointment time, and until then I will be savoring my salad, writing, and not reinforcing inappropriate behavior.

These sorts of incidents with clients are fortunately few and far between. I have a good rapport with my clients, and even in the midst of scheduling mishaps or other frustrations, I tend to find it easy to collaborate with my clients and maintain a good relationship. The agency I work for isn’t heavily tied to other resources for clients and rarely is my word the deciding factor preventing someone’s return to work or reception of disability or whatnot. This sort of role allows the therapy to be more pure, more focused on the individual and the emotions behind their distress. I prefer very much to keep it this way.

Working in mental health, I’m bound to come across some situations with folks who are in the habit of being pushy or demanding of their providers. It’s the same in any service industry really. I usually do a good job of dealing with it, but during times of low blood sugar, my batting average suffers.

I’m terribly excited for a week away from work. It will be wonderful to get some time to clear my head, read a good book, hopefully get refocused. As I’m getting my start in the field, I’m finding that there’s a natural rhythm to how my motivation fluctuates. Motivation might not be the right word entirely. I find myself engaged and present almost all the time for my clients, but my belief in the service I’m providing wavers, and I’m sure this affects the product I deliver.

The closest thing I can relate this hot and cold phenomenon to is the natural ebb and flow of one’s spirituality. C.S. Lewis dubs this, “the law of undulation” in The Screwtape Letters. If my memory serves me correctly, the lesser demon Screwtape writes to his young charge that the best thing they can do to drive a wedge between their patient and “The Enemy (God,)” is to make him feel that this rhythm is a fatal flaw instead of something to be expected. I firmly believe that with my counseling, a fluctuation in intensity of my engagement and belief in it is to be expected.

A week away from the game will be the best thing for myself and my clients to keep us all moving in the right direction. It’s a two-way street, after all, and I need to be recharged so I can continue learning as well. Hopefully when I come back, there’ll still be folks whistling and clicking outside my door, ready to talk and learn and grow.

Actually, I hope they’ll just knock.