In-house #9: Down with Big Brother

Is it immaturity or high standards? Honestly, it can be hard to tell, even after some serious introspection. I despise the Medicaid form of psychotherapy treatment planning so much that I physically cannot do it unless I lobotomize my feelings and grind out tremendous willpower. By the same resistive mental and muscular forces that would prevent most people from filling their mouth with their mother’s feces,* I cannot write the kind of argot that Medicaid expects. A few phrases from The Complete Adult Psychotherapy Treatment Planner:

“Goals: Learn and implement coping skills that result in a reduction of anxiety and worry, and improved daily functioning.” “Objectives: Verbalize an understanding of the cognitive, physiological and behavioral components of anxiety and its treatment.” “Long-Term Goals: Develop an awareness of angry thoughts, feelings, and actions, clarifying origins of, and learning alternatives to aggressive anger.” “Short-Term Objectives: Work cooperatively with the therapist to identify situations, thoughts, and feelings associated with anger, angry verbal and/or behavioral actions, and the targets of those actions.”

Therapists are encouraged to use the treatment plan flowcharts verbatim from such books to produce their documentation. I assume that Medicaid auditors see the carbon copy pap and automatically give it a passing grade. I believe you cannot be penalized if you import these unflavored-gelatin concoctions into your therapy.

And yet, even though clients usually want deeper and more global help than amelioration of a specific symptom (that is, they want to be happy or “to know who I am,” not just to be able to get out of bed in the morning and look for a job four days a week, or reduce marital arguments by seventy-five percent), it must be possible to describe a psychotherapy’s purposes in tangible ways that have nothing to do with Medicaid’s S.M.A.R.T. (specific, measurable, attainable, realistic, time-limited) straitjacket.

So maybe immaturity wins here, because I can’t stomach any concretization or formalization of therapy. A woman has extreme anxiety while driving, following an accident at an intersection where she’d made no errors and had been normatively vigilant. Couldn’t I record: “Client’s goal: ‘I want to be able to drive without fear,’” and “Within six months, client will report that her anxiety while driving is not only manageable but negligible”? I could, and this would be audit-acceptable (probably with some fine tuning). But I resist. That’s because I cannot look at my client and see a discrete problem or symptom or constellation of symptoms. I see a history that has become the problem, an ocean of time and body. I see quantum physics’ “spooky action at a distance”** – past simultaneously affecting the present.

Observe how she was helped. Throughout her childhood and teens, her father had pulled her into being his emotional support person. A solipsist, he knew and cared only about his own needs and feelings. We could say that two problems developed in her early on: the anxiety of the absence of a healthy dependency, no parent to lean on; and the depression of being starved of a father’s love. We never addressed driving, trauma symptomatology, or even anxiety directly. We did grief work, anger work, life meaning work. Within two months she reported feeling calmer and more confident on the road.

Writing this, I see more clearly that I came to this profession to be present at a deep, lonely level with my clients and to help them lose loneliness, distress, lostness and incapacity. This was what I had needed. I had never, in my earlier ignorance and later insight, felt my problem was a symptom. Who does? I believe we therapists reify echoes into problems by soliciting them in a treatment plan. What was “I hurt” or “I have no self-esteem” has now become “I need to be able to express my feelings” or “I need better boundaries with my mother.” What was the core immaturity of a Borderline Personality has become “She goads me on because she knows I can’t beat her up like I want to,” and measurable behavioral goals that rush futilely to it like moths to a flame.

But I am still immature. Because jobs, bosses and having an income demand compromises, compromises that adults prosecute all the time.

But maybe it’s high standards. Because our profession does not require having a boss and playing on his field. It does not require allowing government’s thumb in troubled people’s psyche. Hang a shingle or be an independent contractor. Treat our clients according to our own sight. Eschew Big Brother.

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* The movie, The Prophecy, 1995, starring Viggo Mortensen as Lucifer, Christopher Walken as Archangel Gabriel, and various present-day political figures as the feces.

** Einstein’s derogatory comment about quantum entanglement – http://www.sciencemag.org/news/2018/04/einstein-s-spooky-action-distance-spotted-objects-almost-big-enough-see.