Fast forward. Vermont far behind me, I became a supervisor in a drug and alcohol rehab program when crack cocaine and the AIDS epidemic were decimating communities of color in central Florida.
As an undergraduate in Vermont, I had wanted to be a journalist, but the corporatization disillusioned me. I shifted focus a couple of times and graduated with a degree in literature and creative writing, flirted with the life of a scholar, but, in that role, I felt suffocated, depressed, and imprisoned in my head.
Eventually I came to recognize that clinical counseling gelled my desire to make some positive difference, and I pursued an advanced psychology degree and a counseling license with passion.
I became well read, well trained, and very much inspired by the long history of social workers who had had the courage to right wrongs, to call out systemic injustices and racism, to highlight the obvious roots of multigenerational dysfunction and poverty, and to fight against the disenfranchisement of immigrants, the powerless, and the traumatized.
By the time I was hired into a supervisory position, I was intellectually and skillfully prepared, my cognitive computer stuffed with observations and information from a seemingly endless array of giant minds in the field. I could name developmental models and recite intrapsychic theories on command. I knew how to recognize defense mechanisms, to carefully consider ego-development, methods of self-regulation, and modes of conflict resolution. I could make use of operant methods, attachment research, and cognitive theories. I was educated in object-relations and moral development. I was trained in structural and strategic family therapy and hypnotherapy, gestalt techniques, brief therapies, and long-drawn-out therapies.
I was at home in a world that required curiosity, empathy, and a fervent desire to look beneath the surface, to understand the mental maps that needed to be unearthed to foster my clients’ insights. I gained confidence in perturbing whole family systems to release members from self-sabotaging and injuring modes. I taught crisis counseling in all its forms; led divorce seminars; and spent hours in hospitals with rape survivors, in shelters with defiant runaway teens, and in jails trying to redirect those awaiting first arraignment into mental health courts and drug courts.
And I attended a lot of funerals.
I list all this only to make the point that when I began work in this agency I am about to describe, it felt like it was a consequential place for a young professional, until leadership changed.
Leadership
An ambitious new CEO decided to use an aggressive business model, and he set out to devour other agencies. He got his face on the cover of several business magazines celebrating his growing empire and his management efforts. He announced he was constructing a system based on continuity of care. Unfortunately, in practice, this meant that the organization was quickly becoming too big to care, while negatively impacting hundreds of desperate people, mostly poor, who could not care less about business models.
The company instituted a productivity system to buttress the appearance that the organization was “business-like” above all else. Productivity isn’t as straightforward as you might imagine. Not to get too deep into details, but you do have to wrestle with difficult questions to decide what is “productive” when providing therapeutic services. Giving medications, providing transportation, handing out information, for instance, are activities that are easily recorded. But how do you document, with any validity or clarity, treatment outcomes when addressing complicated problems such as addiction or mental health?
At the time, the Diagnostic Statistical Manual (DSM-II) was transforming from a quick and dirty way for one professional to describe to another the behaviors of their client into the Bible for insurance companies. What had been a somewhat usefully organized list of descriptors and behavioral symptoms became facts—the one reality—somehow. Anxiety meant you had a genetic predisposition. Depression was a disease that needed to be treated as you might address chronic diabetes, with constant and lifelong monitoring. Personality disorders were described as strange character traits that were passed on by genes from one generation to the next. Maybe these couldn’t be cured exactly, but they could be managed by an army of case managers and psychiatrists and medication in a continuity of care.
DSM’s information about substance abuse (SA) was particularly hard to align with people in our program. The entire treatment field was confused. Most times SA was treated like a different animal altogether from mental and emotional difficulties, as if addicts needed to be cordoned off, even housed in different locations. In the community, citizens were also baffled. Addiction was caused by your genes? Was it a disease? A moral failure? A con game perpetrated by seasoned criminals. Maybe addicts needed to get beat up a bit. Locked up. Or maybe they needed to be humbled by an angry religion.
In this climate, it took dedication, compassion, and wisdom as a “provider” to see who was in your office seeking help at any given time. It took creativity and out-of-the-box treatment, an understanding of multiple models of psychological and personality development, and systemic insight, and it took camaraderie to work solidly as a team.
The “productivity” system, adapted from some other realm, was certainly not built from the ground up to seriously measure anything meaningful in the field of mental health and substance use. The technology of the time was clunky and time intensive to exploit, and at odds with the clinical work, but it supported the marketing of propaganda and statistical nonsense spinning out from a growing bureaucratic superpower.
Financial compensation for therapists had always been paltry compared to many professions, but after the bureaucracy was in firm control the work became even less attractive. To just begin to cope with the increasing demand to feed the computerized beast required staying past your shift, working longer hours every day to enter in behavioral data that did not describe the clients, their issues, nor gauge their progress or lack of it.
Garbage in, garbage out. When productivity was determined to be “low,” the management team hired Bob. We have all known our own Bobs. He was brought in from another geographical area to whip the therapists into shape because they clearly were gumming up the machine.
