Sunday, April 15, 2012

And the Walls...

Last week I reached my breaking point.  I have been working week after week 6 or 7 days a week.  Easter weekend killed me.  I did not have time to work.  I got behind.  Then a week full of clients in crisis.  Parents who are so focused on themselves they ignore the strangulation marks on the neck of their child who attempted to end it all.

Therapy is tough work.  Tougher yet is the fact that they are turning a therapeutic model of practice into a business, almost production model of practice.  I am scheduled for 4-10 hour days.  Next week I have one free unscheduled hour.  Likely to be filled by a client in crisis.  If all clients show and don't cancel, I will likely meet productivity at the end of the week for the entire month.  For us, it is 23 hours of face time with clients.  It doesn't seem like much when you consider a 40-hour week, but we are required 8 hours a month of meetings with our supervisor and then there is the advanced clinical consult where we review specific troublesome cases with our colleagues.  Between face time with clients and meetings, we are making phone calls, meeting with other professionals, by phone or in person, writing lengthy diagnostic assessments, writing progress notes, and - if we are good - researching evidence based interventions for various diagnoses.

Insurance companies only pay certain amounts.  We get 1.5 hours for a diagnostic assessment which, when you consider the one hour of face time, leaves us .5 hours to review information retrieved from other agencies, enter PHQs, SDQs and CASII's and other measurements to further define our diagnoses, and write the assessment.  Even more fun is that I am on my 3rd clinical supervisor.  Each clinical supervisor has their own method of writing DA's.  Some want every detail and others want bare-boned diagnostic assessments.  Regardless, our overseer, the Department of Health and Human Services, has requirements that need to be met.  Basically with our assessments we need to establish a case for why our clients require therapy.  Suicidal clients make this easy for us.  Clients who wish to improve their marriage or otherwise work on their relationships make this more difficult.  We have to establish MEDICAL NECESSITY.  Sometimes this is difficult.

Last week I had 5 intakes.  Intakes usually require diagnostic assessments.  Even the best and most seasoned therapists admit that diagnostic assessments take them at least 2 hours outside of face time with clients.  I also had phone calls with clients' parents, school counselors, referrals to additional services, difficulties with the software we use for our documentation, meetings with guardian ad litems, reviewing additional court documentation, crises that require additional attention beyond the session and informal consult with fellow therapists on our clients.  My official work day ends at 7.  Some of my cases are so sick and twisted that I am affected by them.  Since I am the last therapist in the office I don't have anyone to debrief with.  Debriefing is so important when you are dealing with the mentally ill.  It helps so you don't take it on personally.  I don't usually have this opportunity since my day ends later than the other therapists.

So, there is a great deal of stress.  Then, our CEO, or whatever his title is, tells us that we have to meet productivity.  One of the clinical directors sent out an e-mail earlier this year stating if we don't meet productivity, we can lose our FTE (full-time employee) status.  This means we would be reduced to 32 hour status, lower pay and less availability for our clients.  I don't think we have any therapists that can possibly have openings in their schedule.  Where the problem lies is in meetings, trainings and cancellations.  We have no control over clients canceling.  This affects our productivity.  Next week I will be in the cities for 4 days for DBT training.  This training is to fill a need the agency has for people to work with clients with Borderline Personality Disorder.  These clients are referred to DBT groups facilitated by professionals and require a DBT therapist.  We have had therapists leave or quit doing DBT because of the intensity and extra (non-productivity) time required.  So, I lose 4 days of productivity.

In order to keep up on my paperwork, I now work Fridays, Saturdays and sometimes (like today) Sundays.  Since I am salary, I don't get reimbursed for this.  My pay is very low for a therapist since I am not independently licensed.  I need to supplement my income somehow.  This will probably involve working nights and weekend beyond my normal night and weekend work.  I am looking for something within my field to do this, since I think if my clients see me working at McDonald's it may affect my credibility.

Truth is, the bills are not getting paid.  I am getting notices from various medical providers threatening to turn the bills over to collections.  I did my taxes this weekend hoping I would get a substantial refund and this was not the case.

In summary, I am stressed out!  I am getting burned out at my job and now know I need to get another job to make ends meet.  I get angry with people who have taken money from me and still sleep at night!  A couple of weeks ago I learned that Brian closed my line of credit and overdraft protection account.  I was the primary account holder and was told he could not do this.  I will be changing banks soon, as soon as I have time!  When I work 8-7 M-Thursday and Fridays as well, there is not much time to call my creditors or stop in and close my accounts.  The line of credit could have helped with medical bills.  And then I get angry with the residual people who "don't have a problem with him" and continue to have their profile photos adorning his facebook page as friends and "like" his relationship with his new girlfriend living in the home I raised my children in.

Also stressful is that after working this week Monday -Thursday 8-7, I have to go down to MPLS for another procedure to burn my esophagus.  I am more anxious about this after having the last procedure and being unable to eat for 2 weeks.  I will stay with Renee overnight and head back to Brainerd on Saturday to pack for my 4-day training.

One big factor determining the success of our clients is their support system.  When I apply that to myself, I realize that I may have made a big mistake in moving to Brainerd.  I moved away from friends and family that were my support system.  I have a good number of friends here, but they are in different places in their lives, busy with families, children, schools, etc.

There is also the adage that you can't go back.  In several ways I found the truth of this statement when I went back for Easter.  The best part was that Mom remembered me.  The drive down is long and tiring.  It is about 7 and 1/2 hours to get to Sioux City.  I have difficulty with my "excessive daytime sleepiness" a.k.a narcolepsy and fight falling asleep anyway, but driving makes this worse.  I just can't do it.  When staying at Becky's I realized that I likely placed a wedge between myself and her family over Thanksgiving when I expressed my concern about the amount of stress and work she does with little help from Jeff or Hannah.  Jeff was either sleeping or gone the entire time I was there.  I get it.  Shut up Ande.  Don't worry about Becky and the burden she has that will take its toll on her.  I admire her, but I also realize her family has it easy by not helping her with even household tasks.  And I know she can't keep this up without it affecting her.  I also was mistaken in thinking my return might be special enough to prompt a visit by my brother and his family.  I could not take Monday off so I could be with my family on Easter Sunday because I have to meet productivity this month even with 4 days of training!  It is one day of driving each way. I have Fridays off, but then I don't get paperwork done and fall further behind if I am gone.

I Skype with Dad every Sunday.  This will keep us close.  Becky and I talk on the phone and that will keep us close.  I know I am the one who moved away and have accepted it is likely no one will visit me here.  I feel bad that I cannot return often.  Thanksgiving will likely be my next visit if I come then.  It is really dangerous for me to drive that long alone.   Maybe if I find someone willing to switch off driving with me I will be back more.  Right now, I have to say it is simply not likely I will return for some time.  It sounds like Mom is fading again, and perhaps it is best that I remember the her I saw on Easter.  I am so happy she held out that long.

In summation, I feel I am falling apart and running low on outlets and supports.  I realize this, too, shall pass.  I just wish it would hurry in its passing.