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.
** 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.
