07Dec/20

On the Death of Stan Lee

(I originally posted this on Facebook on November 12, 2018)

I don’t have it in me today to write an essay on Stan Lee and what he means to me, but I am compelled to put something together for a human that had a giant-sized (X-Men reference too) role in my life.

I started reading comics when I was seven or eight, and I read more Marvel books on a monthly basis than almost any of you could possibly imagine (not Power Pack though). While I was thrilled by the battles and space odysseys that were oh-so-far-away from my safe home town in Western NJ, I was exposed to a constant barrage of social issues and values that helped shape my worldview all these years later.

It’s funny, because comics in the 1950s were under attack by the government and censorious busy-bodies (often hypocrites to boot) for causing juvenile delinquency. Thus the comics code was born.

The superhero comics that were produced by DC starting in 1938 and Marvel in 1962 were largely written by Jews and immigrants. Faced with bigotry and both in-your-face and hidden oppression, they created heroes that looked upon everyone equally, fought for the little guy, and braved the big battle (alliteration is for you, Stan), despite the serious consequences it may have caused in their professional or personal lives.

Marvel heroes worried about their older family members (Aunt May), had typical romantic relationship problems, and never forgot those that died (Jack Murdock, Uncle Ben, Bucky Barnes).

In the late 1980s, Captain America turned in his shield. He refused to follow the orders of an unjust government. This blew my mind. Those in power aren’t always right; sometimes they are selfish, corrupt or just plain incompetent (this was the theme of the second Captain America movie). Stan Lee didn’t write the “Captain America No More” story, but he approved it. He allowed his creative teams to take risks.

Just this past weekend, the question of values came up when I was with my mother, father and uncle in Washington, DC. My battles with big corporations and institutions were discussed and I was asked some form of the question, “Why do you want to take all of this on?” and I quickly answered, “I grew up reading comic books. I want to fight injustice at every turn.” That shit happened.

Stan Lee had a great life. He was married for almost 70 years, entertained millions (billions?), eventually made a lot of money, influenced 20th and 21st century culture and lived to the ripe old age of 95. I am sad he died, but I’m not deeply mournful. I am forever appreciative and grateful. Thanks Stan.

Excelsior!

07Dec/20

On the 25th Anniversary of Kurt Cobain’s Suicide

(I originally posted this on Facebook on April 8, 2019)

I knew this anniversary was coming up. I was a high school senior when Kurt Cobain shot himself in April of 1994. It had been a rough year for me, as heavy drinking fueled some adolescent legal problems, familial conflict, and a general sense that I had fucked up a winning hand.

I was late to Nirvana. I grew up without cable and didn’t listen to the radio much, other than the classic rock stations out of NYC and the Lehigh Valley. In the spring of 1992, I heard a few songs from Nevermind in the Voorhees High School weight room. I was transfixed. “What the fuck is this?” I asked whomever was around.

“Nirvana. Where have you been?”

Indeed. Where had I been? I bought Nevermind and devoured it. Then back to Bleach. Then I waited with baited breath for word of the next album. I bought bootlegs from concerts, demo tapes, and unreleased b sides.

It was new. It was different. Rock had been angry. Rock had been rebellious. Rock had been mournful. Nirvana didn’t communicate anything particularly unique, but they had a novel sound that spoke to me. It was for me.

I read that Cobain was horrified about the football player bully types who liked Nirvana’s first album, so he wrote this about them “In Bloom”

     Hey - he's the one
     Who likes all our pretty songs
     And he likes to sing along
     And he likes to shoot his gun
     But he knows not what it means

A line from “Smells Like Teen Spirit” has kept my admiration deep into adulthood:

     Our little group has always been
     And always will until the end

I could go on and on and on about the lyrics. But that’s enough.

I was in the cafeteria line in rehab when someone told me that Kurt Cobain had killed himself. I didn’t believe it. Then I did. My initial reaction was very selfish. “No more new music. This sucks.”

My next thoughts were harsh. “What the fuck? He had everything. Amazing talent. Huge sales and critical acclaim. Admiration of millions. Admiration of other artists. Married. Kid. What the fucking fuck?”

Then it was back to group and my own little world. I got home a few days later and read newspaper and magazine articles about it. A Gen X suicide. This generation’s rock martyr. All kinds of horseshit.

I couldn’t comprehend his supposed self-loathing. Not with all that he had. Even with, what I supposed, the disaster I had made my life, the idea of taking one’s own life just seemed so out there and pointless. It made a confusing time more confusing.

The mourning of the fans and the pictures of Francis Bean got to me. My own problems got worse. The MTV Unplugged Album came out. “New music. Great…..I can’t believe he killed himself. This sucks.”

His death caused a collective trauma for millions of people around America, and beyond. Eventually, his self-loathing was glorified. I remember getting angry at people who thought his death was cool. “Live fast, die young, leave a good looking corpse.”

I still listen to Nirvana, all these years later. Not as much. But a week doesn’t go by where I don’t hear one of their songs on my Ipod (yeah, forever). I feel terrible for his wife and daughter and mother. And for people who attempted to justify their own self-injuries and other destructive behaviors by pointing to him. Kurt Cobain was immensely talented. I wish he didn’t commit suicide. I wish he had gone to therapy, quit drugs, and then talked about going to therapy, quitting drugs and addressing his suicidal impulses. He could have made a monumental impact. I’m not angry at him. It all just…sucks.

The music endures. We can learn from his life. And death.

03Dec/20

The Problem with Imposter Syndrome

A few years ago, a former social work student who had started working in Child Protective Services in NYC reached out to ask me how she should deal with Imposter Syndrome.

I hadn’t heard of this before. “What are you talking about?” I wrote back (I usually respond with perfect punctuation).

She sent me this:

I asked her what she was feeling inadequate about.

She responded that she struggled getting through to difficult parents and that she was afraid she couldn’t protect all the kids on her caseload. She told me of a recent situation where she had recommended the removal of a kid from a home and her supervisor blocked it.

I told her that it is often really hard to reach people, and that parents involved in child protective cases can be quite resistant, whether they are abusive or not or negligent or not. Because no one likes having someone else come into their life, poking around and making suggestions for improvement with the threat of losing their kids hanging over them. No one. I reminded her that she took a very tough job that has a high turnover rate because of the stress and quick burn out. And that any good child protection worker would worry about the things she was worried about.

For centuries, people learned their trade or job through an apprenticeship. In the Middle Ages, painters, sculptors, blacksmiths, cobblers, tailors, bakers and other aspiring professionals worked under an expert for a period of about seven years. They watched and learned and practiced and honed their craft. A number of renaissance artists had apprentices and it has been a challenge for all but those with the keenest eyes to figure out what painting was made by Rembrandt and what was created by an apprentice.

21st century society no longer allows for a seven year training period (not even for doctors). We are too rushed and living is too costly. So people get a quick education, often a shitty internship, and then they are hired into a job with a bad boss or poor supervisor and thrown in the deep end of the pool and left to figure it out.

There are terms for new people: rookie, private, freshman, beginner, fng (fucking new guy), cub, novice, newcomer, trainee, first-year, adept, initiate and tenderfoot. There are a bunch of others.

Those names exist for a reason. I thought about that conversation a few months later when I saw that a first term US Congresswoman tweeted that she struggles with “the imposter syndrome.”

Being new doesn’t mean you are an imposter. It means you are new. And that there is a lot of stuff you don’t know. And it takes time to learn. And the best way to learn is to watch and copy and ask questions of someone who is a little bit ahead of you.

If you are in a great school because your celebrity parents paid for a coach to lie and say you were great at swimming, you are an imposter. If you are an executive at a real estate company because your Dad owns it, you are probably an imposter.

If you are a first year nurse or a new school social worker or a rookie cop, you aren’t an imposter. You are just new.

With rare exceptions like Kevin Maas, Tyreke Evans, The Killers, and Ryan Gosling, most people don’t peak in their first year. If you are in the first year or two of a career or new position, it is probably going to be a bit of a challenge and you will sometimes doubt yourself and occasionally be overwhelmed. This is natural and proper and expected.

When I was in my early 20s, I wrote a poem to myself:

Most of us need polishing. Because we are new, not imposters.

If you still need a bit more reassurance (or are someone who has been in your job a long time and still feel like a fraud), go over these questions with a friend or family member or colleague or therapist or someone else that you trust (and can hear):

  1. Did I prepare for my job/position/career with a formal academic education or trade school?
  2. Did I fully apply myself in that education?
  3. Did I have an internship or apprenticeship or formal training period?
  4. Did I have a supervisor or mentor or trainer who met with me regularly and whom I asked a lot of questions?
  5. Did I lie or cheat or have sex or pay money to get this position?
  6. Am I still being trained or supervised now? If so, is my boss helping my development? If not, can I find someone to help polish me a bit more?
  7. Do I consult or chat with other people in my line of work?
  8. Have I read about other people’s experiences in this field? If not, will I?
  9. Do I show up early and/or stay late?
  10. Am I trying my hardest?

Someone told me recently that Imposter Syndrome was burning up on various social media platforms and people were claiming to have it and that it should be a diagnosis. No and no. Look, ask Google for directions or Alexa how to scramble eggs or Siri who wrote The Guns of August or Facebook for the best Pink Floyd Album, but don’t ask them or other social media to help you pick a romantic partner or figure out if you are doing a good job at work.

Everyone could benefit from a mentor, regardless of whatever stage of work or life you are in.

Back to my former student: she’s kicking ass in her job and is now helping new social workers get acclimated at CPS. I’ll end this with some recent words of wisdom from her, which can sum it up better than I could:

“You were right. I was just new.”

22Jun/20

My Frustrations with Humanity

I have labored, really labored, to improve the lives and conditions of others for almost 20 years. There have been a great number of individual triumphs – lives turned around, families restored, jobs saved, and lessons taught. And yet, the 21st century has seen a fair share of horrors and 2020 has been utterly disastrous for so many people all over the world. When one takes a hard look around, it is easy to get frustrated. Exhausted. To even consider packing up and isolating in a forest on a mountain in order to avoid falling to despair. In good times and bad, I often seek solace and answers from literature.

In the prologue to the Wife of Bath’s tale in The Canterbury Tales, Geoffrey Chaucer offered up the following line that I often think about: “The wisest man minds his own business and does not worry about the conduct of the world.”

Because if you worry about the conduct of the world, you will be perpetually frustrated and often aghast. I can understand why someone would just want to retire to their library or garden or “sail away from the things of man” (this is a line from the terribly underappreciated Joe vs the Volcano).

Huckleberry Finn had enough of humanity to decide that he wanted to float away on a raft because civilization was terrible. Life on the raft with Jim was wonderful, and every time he went ashore he was yet again confronted with awful examples of human greed, racism, selfishness, anger, and violence. In the middle of Twain’s novel, Huck observed a group of townspeople tarring and feathering two con men and said, “Well, it made me sick to see it; and I was sorry for them poor pitiful rascals, it seemed like I couldn’t ever feel any hardness against them any more in the world. It was a dreadful thing to see.  Human beings can be awful cruel to one another.” By the end of the novel, Huck’s alcoholic and physically abusive father is dead and Jim is freed, yet Huck decides to leave civilization anyway and make out for “the territory.”

Like Twain, Shakespeare despised the mob (not the Northern NJ Italian type) because they were rash and violent and fickle. At the start of Julius Caesar, the people are out in the streets celebrating Caesar’s latest triumph. Marullus and Flavius, two Senators, engage a few of them in conversation before Marullus chides them, “O you hard hearts, you cruel men of Rome, Knew you not Pompey?” Because they used to cheer and celebrate Pompey before he was defeated by Caesar. Throughout the play, Shakespeare does not take a stance for or against Caesar, but he clearly has great disdain for the quick turns that humans take and how easily they cheer other people’s destruction.

Throughout human history, religion has sought to temper these violent impulses and drive away the worst aspects of humanity while encouraging kindness, charity, and peace. In theory.

In the Narrative of the Life of Frederick Douglass, many of the absolute worst people who beat and murder slaves are “pious souls” and “devotional” and one is “a class leader in the Methodist church.” Not only has religion failed them, but it is used to prop up these heinous people. Some of them even use religion to justify their abhorrent behavior. His autobiography provides such a devastating indictment of American Christianity that Mr. Douglass felt the need to explain it in the appendix: “between the Christianity of this land, and the Christianity of Christ, I recognize the widest possible difference – so wide, that to receive the one as good, pure and holy, is of the necessity to reject the other as bad, corrupt and wicked.” While American Christianity (in all its many flavors) is far more enlightened in 2020 than it was in 1845, there is still a rampant hypocrisy that seeps out of churches throughout the land.

In the excellent show Good Omens (written by Neil Gaiman), there is a scene in episode three where an angel and a demon are watching the Crucifixion. The demon asks the angel what Jesus said that so offended those around him. “‘Be kind to each other,’” the angel informs him. “Yeah,” the demon replies, “that’ll do it.” It’s a funny and scathing moment.

As a student and now teacher, as a reader and now writer, as a therapist who engages in work on the micro, mezzo, and macro levels, I am continually reminded that people are amazing at pushing their perspectives and largely being unable to see other people’s sides. Most people that I talk with about culture, society, politics, work, religion, gender, race, sexuality, or class tend to lead with and focus on their experiences and their grievances, rather than listening to others. People love to tell others how to live. Again, I’ll cite Twain: “Nothing so needs reforming as other people’s habits. Fanatics will never learn that, though it be written in letters of gold across the sky.”

I got sober at 19 with the help of treatment and ongoing therapy and AA meeting attendance. AA was brilliant in that it had me focus on myself, my problems, my flaws, my behavior, my part, and what I could change. I was exposed to the the Prayer of St. Francis, which provides excellent advice:

Grant that I may
Not so much seek to be consoled as to console
To be understood, as to understand
To be loved, as to love
For it is in giving that we receive
And it’s in pardoning that we are pardoned

About ten years ago, I was counseling a student at Rutgers who was a finance major who had a job lined up with a Fortune 500 company. His plan was to spend a couple of years there and then to get his MBA so that he could return to Wall Street and acquire more power and make “some real money.” With that line, he summed up the true religion of modern America (go read Ayad Akhta’s Junk and then you and I can talk). I remember thinking about how there are some people that don’t deserve my help; I understand that few people will actually engage in meaningful work that improves the lives of others and leads to the betterment of society, but I think that people should at least follow the Hippocratic oath when looking for work: “Do no harm.” I wrestled with the notion of whether or not I should help someone who would profit off the work of others while contributing nothing to the world, and in fact, possible working on destabilizing the economy and getting rich while others have less and less. I ended up giving him the exact same attention and care that I would have anyone else.

This piece isn’t written for everyone. In fact, it is for a minority of people. Those that are good and that are trying to better the lives of others. Not in theory, but in practice (years ago, I was friends with someone who had an astonishingly distorted view of himself. He thought he was a wonderful person, but he was incredibly selfish and argumentative and ended driving a lot of people, including myself, away). It is easy to be frustrated. At any time. But certainly now, in 2020. Not just with the pandemic or systemic racial injustices or economic disparities, but a litany of other problems too, including, most significantly, climate change.

Thoughts of giving up or quitting and sailing (or floating or hiking) away are normal. And rational. But these feelings and this debate are not new. J.D. Salinger wrote about it The Catcher in the Rye. Holden Caulfield was horrified with society. The book was published in 1951 and as a rich young white male, he was certainly in that era’s great winners’ circle. He had, in fact, been exposed to very little and was still thoroughly upset. Near the end of the novel, he meets up with a former teacher of his, who offers some wonderful advice that I also often lean on:

Among other things, you’ll find that you’re not the first person who was ever confused and frightened and even sickened by human behavior. You’re by no means alone on that score, you’ll be excited and stimulated to know. Many, many men have been just as troubled morally and spiritually as you are right now. Happily, some of them kept records of their troubles. You’ll learn from them — if you want to. Just as someday, if you have something to offer, someone will learn something from you. It’s a beautiful reciprocal arrangement. And it isn’t educational. It’s history. It’s poetry.

Of course, the advice is muddied when that same teacher starts petting Holden on the head while he is sleeping. Holden wakes up and runs off, thus further alienated from people. Still, the advice is very good. It was a brutal stroke for Salinger to give that to the reader and then have the speaker attempt to molest the protagonist.

I am frustrated with people and Americans in particular (this has been a two decade thing, by the way). The news is upsetting, comments at the end of articles are often sickening, and the selfishness and conflict that seem to pervade so much of our modern world understandably urges me to throw up my hands and say “Enough with the lot of you” and leave the mess because, in Roger Water’s words, “it’s not easy, banging your heart against some mad bugger’s wall.”

Humanity is the mad bugger. Clearly.

And yet. I choose to stay. And work. And help. And hope. I am inspired by the work of others; by their effort, their care, their perseverance, their stories. It is possible to hold the conflicting thoughts that humanity is often terrible and yet I’m going to stick around and help them anyway. So, don’t give up. We keep trying til the very end. Just make sure you stop and smell the roses, walk among the lillies, watch the sunsets, and laugh a bit.

13Jun/20

Police Are Serving on the Frontlines of the Heroin and Opioid Epidemic

*note: I wrote this in March of 2017 for a website that is now defunct. I stand by the sentiments herein. I have been thrilled with the police response to working with people with substance misuse disorders and the willingness of many departments to change their longstanding procedures. I believe that with proper recruitment, training, and supervision, the profession can continue to evolve and improve.

——————————————————————————

In 1971, President Richard Nixon declared the war on drugs. There was a brief respite under President Carter (who unsuccessfully called for the decriminaliziation of marijuana), and then President Ronald Reagan ratched up both the rhetoric and incarceration rates while also cutting funding for treatment. Presidents GWH Bush and Bill Clinton continued to spend billions trying to arrest away the drug problem. The roots of the modern opioid epidemic began during the Clinton and Bush II administrations with the aggressive marketing of pain killer by companies like Purdue Pharma. While incarceration rates have gone down the last few years, the United States continues to be, by far, the number one jailer in the world in both rates and total numbers.

The Vera Insitute of Justice estimates that the US spends about $75B a year on corrections, and this does not include capital building costs or pensions and benefits for corrections workers. For that money, over 66% of ex-offenders are arrested again within three years and almost 50% return to jail or prison within that same time.  It has been a terrible return on the public dollar.

Despite the money spent on incarceration, drug overdose rates in America have increased from about 23,000 in 2002 to over 50,000 in 2015. Drug counselors, law enforcement, policy experts and politicians started sounding the alarm at the end of the last decade. The Massachucettes Bar convened a Task Force in 2008 and released a report. Other states and counties followed (I chaired the NJ Heroin and Opiate Task Force in 2012 – you can read our report here). Forward thinking governors  began to pay attention, and both Democrats (Pete Shumlin –VT, Andrew Cuomo – NY) and Republicans (John Kasich – OH, Chris Christie – NJ) accepted the Affordable Care Act’s Medicaid Expansion and instituted new policies to combat the epidemic (the implimentation of Prescription Drug Monitoring Programs, Needle Exchange Programs).

I have trained thousands of law enforcement officers in multiple states (I’ve also provided counseling to many). Whenever I conduct a training, I ask them why they joined the force. While answers like “I was in the military and missed the uniform and comraderie” or “It’s a family business” or “It is a good job with benefits,” the most common answer has always been “to catch bad guys” or “to help my community.” Police have been the action arm in the failed war on drugs for decades. Not only has it not been effective, but it has burned out a few generations of cops. The drug war violated the rights of many Americans (dis-proportionally people of color) and it inflamed conflict and negative views between minority communities and the police.

After decades of arresting
millions of people for small possession, 
law enforcement officers started to make changes on the local level.
Veteran police officers talked about how they had spent their careers busting
people for drug use and that the problem had only gotten worse. Other cops
stated that the focus on low level drug busts and arrest stats took the focus
away from more important crimes that required more work – burglaries, violence,
and sexual assaults. As drug overdose deaths continued to skyrocket this
decade, police officers began to carry Naloxone. Only a few departments used it
in 2012, but more and more added it to their basic equipment each year and now
it is standard in most departments throughout the nation. Police officers
administer naloxone to individuals who are overdosing more than any other
professional group.

While many veteran officers
support this change, young police officers often wonder “what is the point of
using Naloxone on a drug user?” Law enforcement officers occasionally express
frustration over administering Naloxone to the same individual several times
over the course of a few months, or reviving someone with a long criminal
history, or reversing an overdose of a person who has obviously been neglecting
their young children. This frustration stems from both a lack of training on
addiction and a overall macro level failure of public policy.

Naloxone was given to police
and first responders to reduce the number of overdose deaths. But there was no
initial follow up plan, so after a drug user was revived he was just sent on
his way. Over the last few years, a number of police departments (or county organizations)
have created programs to assist drug users after they have been revived. Over
the last three years, new programs (often called PAARI – Police Assistance
Addiction and Recovery Initiative) have sprung up around the country. Programs
like Angel in Gloucester, Massachucettes were set up to help heroin users get
into treatment instead of arresting them. Some programs have an embedded social
worker in the station (Arlington, Mass), while others hand out information
about treatment (START in Hunterdon and Somerset Counties, NJ), while others
take them to local hospitals and detoxes (Operation SAL in Camden County, NJ).
Most police departments have not developed a program yet to better handle the
people that they have revived. There are enough models that departments can
choose the one that best fits their department and municipality.

It is important that police
get training on this issue from someone that is knowledgeable about drug
treatment, state and federal policies, and also has a working knowledge about
law enforcement work and culture. In the last two years, there has been a
number of for-profit treatment programs that have attempted to train police and
set up relationships with departments in order to funnel clients with cadillac
insurance to their rehabs. Not even senior law enforcement leaders know the
difference between a non-profit program that uses modern data analysis and a
predatory for-profit program that has no interest in assisting indigent
clients.

The War on Drugs failed. Both
Democrats and Republicans have finally said so. Law enforcement knew it before
the polticians did. Now cops are the ones that have made the biggest change,
and they need proper training.

04May/20

Ethics Interview

A young woman who is in graduate school reached out to me with some questions about ethical and legal aspects in the mental health profession. I liked the questions and decided that I would just share my responses with my readers.  

  • What does being a legal and ethical mental health professional mean to you?

It is important that I follow federal and state laws and regulations regarding my work. I have multiple licenses in NJ, NY, and PA, and each state is a little bit different. The laws are there to protect the client: their care and confidentiality are of utmost importance.

I think there are a lot of awful programs and bad providers out there. They cut corners, claim an expertise that is not there, over bill, over diagnose, don’t get or engage in supervision, and really seem to put themselves and their programs ahead of the clients.

For me, I have to maintain an ethical and legal standard that not only far surpasses the average citizen, but provides a model for other health care professionals. I was trained to put patients first, document everything, and act like anything I do will be reported in the Star Ledger or New York Times.

  • What are some firsthand legal and ethical challenges you encountered in your clinical practice? How did you handle the situation?

I had finished up my first year of graduate school in 2005 and was offered a counseling job at a small private practice. On my third or fourth day there, I learned that the owner and head therapist was employing a number of the clients in a side cleaning business. This was a clear violation of boundaries. I asked her about it and she said that she provided a good job for clients that had a hard time finding work. I brought up the NASW code of ethics and she said that the client’s ability to put food on their table and pay their bills was more important. I quit and reported her to the licensing board.

In 2012, I chaired the NJ Heroin and Opiate Task Force. We held hearings around the state. We wrote a report in 2013 that included recommendations to the Governor and the Legislature. Governor Christie’s office sat on the report for almost a year. Frustrated, I began to criticize the Governor on the radio and in various newspapers. Around that time, a complaint was filed against me with the the State Ethics Commission about how I used my role on the Task Force to advance the interests of Rutgers. Upset about this horrifically vile lie of a charge, I reached out to Gov. McGreevey. He was on the Task Force and had been providing me with political guidance for a couple of years. He told me that “this is great. You’ve done nothing wrong. There is no sex, no money, no contracts. You’ll be exonerated. In the meantime, you are going to learn a great deal about the dirty nature of politics.” It didn’t feel like a great experience. It lasted a year and I was fairly stressed out about it. Ultimately, I was found to have not engaged in any wrong doing. Rutgers was wonderful too – they said that if I had done anything wrong, it was Rutgers fault and not mine. To my great satisfaction, the individual who filed the false complaint against me lost his state job and was barred from future public service.

About five years ago, there was a program that I did some part time work for that had a new clinical supervisor that was not providing weekly supervision to the counselors that worked underneath her. I expressed my concern to the owners on multiple occasions through text, phone calls, and emails. I was told that it would be addressed. It wasn’t. I anonymously reported the situation to the state. A day or two later, a state worker reached out to me to let me know there had been a complaint at an agency I worked at and that they were giving me a courtesy heads up. I was infuriated, and told them that I had made the anonymous complaint. Nothing was done. I filed a second complaint on the state’s website. Someone reached out and eventually, the supervisor started provided weekly supervision to the workers. This whole process took three or four months.

A couple of years later I was asked to provide consultation for an outpatient treatment program in NYC. I learned that all of the front-line counselors had been trained to type that their individual and group counseling sessions used motivational interviewing or cognitive behavioral therapy, even when the counselor had little to no idea about those techniques. I expressed my concern to the administrative supervisor and the owner and was told that they do this to stay in compliance with NY’s OASIS regulations and the insurance companies. I told them that it was unethical and that staff needed to be fully trained on these techniques and then to actually implement them. There were other issues; soon, I reported the company to OASIS and resigned.

I don’t expect most mental health professionals or social workers to act like I do. It would be nice, but it is unrealistic. I left jobs and put myself in situations where the state and corporations (a couple of very rich ones with lots of lawyers) came after me. I’m willing to do the right thing even if it puts me in financial danger – I have found that a vast majority of people are unwilling to do that. A lot of times people will say “I have a mortgage to pay” as the reason why the go along with something bad or “I can’t deal with the drama” as to why they don’t report something. Those are terrible excuses. Other times people will say they have a spouse and kids to provide for. This is a bit more understandable but still ultimately wrong.

  • From your perspective (whether or not you work with insurance companies), what are the advantages of insurance panels, what are the struggles? Any legal and ethical implications arise as a result of working with insurance companies?

I dislike the insurance companies. I’ve spoken and written about this for over ten years. Insurance companies make money by (a) not paying claims or (b) paying as low an amount as they can.

From 2005 to 2010, I worked at a non-profit intensive outpatient program in Western NJ. I conducted evaluations there and made treatment placement recommendations. More often than not, when I said a client needed to go to inpatient treatment, their insurance company would come back and say that they would approve intensive outpatient only. But if they failed at that level, then they would consider inpatient. This was upsetting to me. I would argue with them, and I usually told the insurance people that I would have no problem writing a letter on behalf of the client’s family if the client overdosed or died that would be used in court to show the negligence of the insurance company that went against my recommendations. Sometimes it worked. Over the years, I have acquired more licenses, more certifications, another masters, and several titles. Insurance companies fight me less and less on these issues, but it is only because of my rank and that I am profoundly aggressive with them.

I have a lot of disdain for mental health professionals who work for insurance companies. Their job is to go against the treating professional’s recommendation and to lower the cost of treatment (and thus securing more profits for their paymaster). I am sure there are some ethical licensed professionals that work for insurance companies and advocate for clients, but I think they are quite rare. Quite rare. For the last ten years, I have taught at the Rutgers School of Social Work. I tell my students that they can always reach out to me, unless they work for an insurance company where they deny or reduce claims. If they do that, they are dead to me. Unless they took the job in order to become a whistle blower.

I am not on any insurance panels. I don’t want insurance dictating how long or how often I can see someone. I don’t want to get on the phone and talk to some officious bean counter about how the client is progressing and to take marching orders about how they want me to proceed. I am also very much against insurance companies telling me how much they will pay me. I understand that most clinicians need to be on panels in order to get clients and make a living, but they have ceded a great deal of power and authority to those insurance companies.

This has happened throughout the medical profession. Doctors really screwed things up by giving in to the HMOs and insurance companies in the 1980s. But that is a story for another time.

  • What does a good case note look like, what should be included or excluded? What advice can you give about effective record keeping in general? Is there information that you may reconsider recording due to legal and ethical reasons?

It depends. I tend to not take notes in the Army or with the NY State Police, as I don’t want command to use the notes against those that I treat. Those are unique jobs and unique situations, and not something that I would advise new professionals to get involved with.

But I think that good notes are really, really important. One should write down the day and time you saw a client, how long the session lasted, what was discussed, what plans were made, and a separate analysis of how the client seemed (grooming, language, facial expression, affect).

Over the years, I have reviewed my notes with clients when they are stuck on something. For example, if someone said they were going to write their mom and letter and then didn’t, I would go back to the notes and say, “Hey, seven weeks ago we talked about this and you agreed to it. Then we discussed it again four weeks ago and you said you would do it. These are your words, not mine.” It can be effective at getting clients to move forward.

If you treat a lot of people, the notes are also helpful to the provider as to the client’s history, situation, and plan.

I’ll leave it at this – if you don’t document it, it didn’t happen.

  • What factors contribute to your decision of terminating the provision of therapy? How do you approach this process? What ethical aspects must be considered when introducing the idea of therapy termination to a client?

When I’m treating people, I constantly ask how the sessions are going for them. If they are seeing any benefit. What is hard for them. We discuss how long we might work together. Sometimes it is time limited and other times open ended. We regularly discuss it though. When I was in Poland last year with the Army, it was clear that my sessions with clients would end once our deployment was over (that said, I told soldiers they could reach out to me via phone, email, or online if something came up). We discussed what we worked on and their plan going forward and whether or not they would seek additional counseling from someone nearby when they returned to the States. Those are the topics that a mental health professional must cover when they begin to terminate with a client. At the very least, termination should start being discussed when you are halfway through. I do it from the start of treatment though and continually review it.

30Mar/20

A COVID-19 Reacction: Most Public-Service Minded Peoples’ Roles Come Later

This was not an article I planned to write. It is in response to conversations with a half dozen people who feel guilty/useless about being at home while health care workers, cops, and some National Guard service members are on the front lines during the initial phase of the 2020 pandemic’s wave.

Some people are able to help from home: sewing masks, coordinating volunteers at food pantries, or providing counseling or support via phone or Zoom. Most aren’t though, and so they are left to logging crazy hours online, wandering around their house, opening and closing kitchen cabinets, trying not to freak out at their spouses or kids, and beating themselves up that they aren’t doing something to help other humans during COVID-19.

To be brief: let the health care workers, law enforcement officers, and activated National Guard soldiers and airmen do their thing. They are needed now and have a very distinct purpose. Most of us would just get in the way and muddle things up.

Our part comes later. A former student of mine is currently getting his Masters in Public Policy at Princeton. Before going back to school, he worked for the government examining ways to reform and improve healthcare delivery and find ways to save the public money. On Saturday morning, he wrote me: “The only difficult part is that I’m not in public service right now, which makes me feel a bit useless.” I told him that his role in this comes later. Whether it is evaluating our Federal government’s horrific preparation in January and February or the pre-pandemic lack of needed medical supplies or devising programs to help people deal with the long term health and economic aftermath, he’ll do something necessary and good. Just not right now.

I continue to teach and counsel. I’m able to do so from the comforts of my home, where I have power, heat, internet, plenty of food, books to read, plays to write, and a garden to use as a calendar to mark the procession of time. I am providing counseling and support to about two dozen NY State Troopers and soldiers who are on the front line, as well as a few nurses and doctors that are working crazy days in NYC hospitals. I’m able to work and help, but not like I really want to.

My part comes later. As of this morning, there are over 141,000 Americans that have tested positive for COVID-19 and at least 2,300 that have died. This is just the start. Some models predict that tens of millions Americans will be infected and that over 200,000 may perish. No one knows for sure. But one thing is clear, the stress from the job losses and the massive economic hit that we’ve already taken (and which will worsen) is and will be incredible. Odds are that most of us will know someone who dies from this. There will be a great need for grief counseling and support. I expect it will be much of my work for the next two years.

So, please don’t fret or beat yourselves up over what you aren’t doing now. Stay home. Think about what comes next or after. And make sure you are able to do your part when called. You will be sorely needed.


Two resources:

The New York Times answers questions on COVID-19

An excellent source of COVID-19 information for NJ, NY, PA, and CT

31Jan/20

How Teletherapy Will Suppress Social Work Wages

Teletherapy is the online delivery of therapeutic services (addiction, mental health, basic counseling) through Skype or Facetime or preferably a more secure video conferencing site. I have been at a few conferences and symposiums where the the subject of teletherapy was discussed.

Every single person that brought it up waxed about the benefits, which include: (1) allowing people in remote areas to access care; (2) allowing people who have a difficult time leaving their homes to speak to a professional (disability, obesity, agoraphobia); (3) connecting with a specialist who lives very far away; and (4) convenience.

The strongest arguments for teletherapy that are usually put forth are those first two points. While I have some concerns about privacy, security, and safety, I deeply believe that therapy needs to be an in-person experience where people can give each other their complete attention and full heed can be given to body language. But I am neither writing nor arguing about that today.

Teletherapy right now is being offered up as a counseling solution for people in remote areas or that can’t leave their home. A few programs and therapists are currently using it as a supplemental service after someone leaves an inpatient program or are traveling. Over the next few years, large health care corporations will establish themselves as the primary providers of teletherapy. Because they do not need to pay for a physical space and can hire remote workers, the cost of providing teletherapeutic services will be lower than in-person sessions. A MBA or some other bean counter whose sole focus is profit will then say, “We shouldn’t just offer this service to people that are disabled or in remote locations. Rather than being a special service, we should make teletherapy the norm. Think of the profits!”

Social work is a field that is well over 80% female. Because of both the nature of the work (helping the sick, poor, downtrodden, oppressed, cast aside) and the gender of the workforce, American society has put a low value on the labor. Despite its importance. The wages are extremely low compared to almost every other field, especially when we consider that it generally requires a Masters level education. In addition to their full time employment, many social workers work a part time job (some even have a third or fourth job, or a second full time job) in order to make ends meet.

Increasing the amount of teletherapy will suppress wages further. Ours is a field that really can not permit further wage suppression. Social workers and their professional organizations (NASW, ASWB) need to be aware of this. If they don’t, they sign their own professional death warrant.

09Nov/19

On Veterans Day, Consider Armistice Day

In 2015, I answered some common questions about Veterans Day. Last year, I wrote a story about a moving conversation that I had with a soldier who had overcome an addiction to opioids. Because I’m serving in Poland with the US Army this fall, I’m looking at Veterans Day a bit differently.

The eleventh hour of the eleventh day of the eleventh month of 1918 marks the unofficial end of World War I (the Treaty of Versailles in 1919 officially ended it). A few weeks ago, I noticed that the British soldiers on base were wearing red paper flowers. I recognized them as poppies and asked them why they were wearing them before November 11th. The red poppy is one of the two defining images ‘In Flanders Field,’ the most famous poem written about those that died in the Great War. One officer said that they wear them everyday for a few weeks leading up to Remembrance Day. An American sergeant in the room blurted, “That’s the same day we celebrate Veterans Day.” I stifled a glare and withheld a withering comment and said that both commemorate the end of World War I. Over a century later, Great Britain, Canada, Australia, New Zealand, France, Belgium, and a few other allies and commonwealth nations continue to remember the day and solemnly hold ceremonies. I’ll come back to this.

Poland recognizes November 11th as their National Independence Day. While the culture is well over 1,000 years old, Poland was partitioned in 1795 between Russia, Prussia (part of modern day Germany), and the Hapsburg Empire (modern day Austria). The country ceased to exist, at least as a form of government or on a map, but the language and proud culture survived during that 123 year period until Poland re-emerged out of the ashes of the Allied victory at the end of World War I. They had been partitioned two earlier times in the 18th century and endured previous invasions from the Russians, Teutonic Knights, Prussians, Tartars, and Swedes. Poland was often defeated but never truly conquered. In 1939, Germany invaded from the west and Russia invaded from the east. 85% of Warsaw was destroyed by 1944. The Germans were eventually driven out but the Russians turned out to be another cruel despot that directly or indirectly controlled Poland until 1989. Of the 195 countries that are recognized by the United Nations, only a few may have suffered the horrors of war worse than Poland. One can argue that no country has had more menacing neighbors. Today, Poland still casts a wary eye eastward.

World War I was originally known as the Great War. It was once called ‘The War to End All Wars.’ The total deaths suffered by the allied forces were about six million while the central powers numbered around four million. One must note the additional 20 million service members that were wounded; as well as the civilian casualties that were so difficult to determine. The numbers are staggering (they would be dwarfed by the death toll of World War II; which because of the stark villainy and the recency has pushed WWI to the background of most peoples’ minds). Families were shattered; towns were emptied; cities were destroyed; the western world suffered a collective trauma. The end of the war led to mass celebrations around the world. More significantly, people hoped that humanity had learned a lesson through this catastrophe and would keep the peace. Armistice Day would not just remember the end of the Great War, but it was supposed to be a yearly reminder that everyone loses in war and that we must strive for peace. The British soldiers I spoke with still know this lesson.

Not so in America. Armistice Day eventually morphed into Veterans Day. Now it’s a national holiday where people drink beer, save money when shopping, post near-meaningless support  on social media, and some veterans get a “thank you for your service” (which less than half of them like to hear).Civilians often express compassion, gratitude, or guilt when they see the Marine with one leg or the soldier with no arms and one eye. They wonder or suspect or fear the hidden wounds of PTSD (or C-PTSD). Most Americans only think about veterans when they watch a war movie or a politician uses them on a stump speech or they bump into one or on Veterans Day. Ask people about veterans and you’ll usually hear enthusiastic bellowing. Businesses trip over themselves to say that they are veteran friendly and they outdo each other by flying giant flags to show just how much they care and demonstrate their level of patriotism. Because they utter some words and because they fly a flag. Service members and veterans have become a pretend sacred cow in the United States; they are supported with token words. And ovations at sporting events (this intersection of sports and the military is particularly galling, because it doesn’t address the policy problems in the Department of Defense and it serves as a vile recruiting tool for children and teenagers in the stands). The military perpetually screws over those that serve (instead of a “thank you,” ask a service member or a vet if their military branch ever fucked them over). The VA continually churns out disaster stories.

And yet. Veterans Day. Despite the holiday (such a bad word choice for November 11th), the movies, and the gratitude & guilt, we, as a nation, seem to be failing at recognizing the real reason for pausing on November 11th.

War is horrible. For those that serve; for those that wait for them back home. For the nations that lose. For the nations that supposedly win. For everyone. We need to do better. We must work harder to attain and maintain peace. Not just between nations but also between individuals.

This problem is as old as human kind. Plato wrote “Only the dead have seen the end of war.” He died well over 2300 years ago and those words still ring true.

For those of you reading this as an anti-American verse, you are painfully mistaken. For those that think this is a full-throated cry for pacifism, again you are mistaken. Sit with me and I’ll tell endless true tales that will erupt sorrow and rage in even the sunniest plastic patriot. I want us to be better. To not debase others. Or dehumanize them. Or use the military as a knee jerk response. If you speak with violence, talk of invasions, celebrate fighting, or glorify war, I invite you to spend some time on the front lines helping with the aftermath. Ponder the father who outlives his son or the child who grows up without a mother. Think on the veteran who mourns his fellows. Picture a spouse in a forever lonely bed. Visualize the soldier who is jarred awake from near-nightly nightmares. Consider the cities that have been razed, the cultural artifacts that have been destroyed. Wonder about what books the dead might have written or the diseases they may have cured. Meditate on the folly of it all. And work towards peace. Among nations. Among yourselves. This Veterans Day. This Armistice Day. Be better.