Karin’s Group (at Rogers Hospital

The first thing I did before starting my group was attend “big group,” an open-ended process group that included all the patients currently in the program. The primary therapists (PsyDs and PhDs) rotated leading the group so it was a little different each day. I knew right away I didn’t want to duplicate “big group.” I noticed time was often used up by a few of the more talkative or controlling patients while the shy ones hid in the bushes hoping not to be called on.

Most of the kids returned home and I wanted them to be better equipped to handle the issues that had resulted in their hospitalization. Surely, these same issues awaited them. So, my focus was on social skill building, improving communication and decision making.

My first group session was a disaster. I was fresh meat and they chewed me up and spit me out. Out of control, disruptive and disrespectful. Luckily, later that day, the head of the rec-therapy department showed up at my office door and gave me a short tutorial on getting control of this mob of manipulative kids.

Basically, this is what he said: next time in group, the first time someone acts out, even if it’s just flicking an eyebrow, you stop the group and give that patient negative behavior points and have them taken back to the unit. As they are leaving, go back to whatever you were doing so they can see life goes on without them. And best of all, the whole group sees that you are in charge.

When I did this, everything changed. Once back in charge, I began introducing a topic for each group, discussion topics and activities that promoted group cohesion and support. Whatever the discussion was, at the end there was a go-around and each patient was expected to contribute.

For example, one day the topic was heroes. First, an open discussion. What does it mean to be a hero, how does someone become a hero? At the end, I asked the group to identify a personal hero of their own.  I modeled by identifying and talking about one of my own heroes. Then I asked for volunteers to do the same and we worked our way around the room until everyone had spoken.

It was amazing what came out of this exercise. Touching stories of a parent, a foster parent, older brother, valued friend or teacher who was looked up to and why. Group members learned important things about each other and felt less alone. This was what I was going for.

And I especially liked hearing from everyone. I’d chuckle as we headed down the stairs to the group room; They were so nervous, knowing they’d have to talk. I’d be bombarded with anxious questions of what are we talking about today?  Of course, I never told them.

I developed a rotation of topics that I used and re-used since this was a short-term program. But I also changed things if there was a certain issue that needed discussion. For example, I’d noticed a time when there was a higher than usual amount of swearing. So, I announced that for one session we’d have a no swearing group.

After the grumbling and complaining, I explained by saying: okay. I’m not being a goody two shoes. Hell, I swear sometimes too. But, damn it, once you go home, you’ll be in situations where you need to ask for something or bargain for something and swearing will make a bad impression. Swearing at your principal is not a good idea. I just want you to have some practice at expressing yourself without depending on swear words.

They got it. We had a productive group and though this was just one session, for weeks afterwards, kids would point out to me with pride when they hadn’t sworn, not even once, in group that day.

The adolescent program was treated differently than other patient groups. An example was the Florida Room, a beautifully decorated room off the main lobby. It was used for special parties and meetings and occasionally some of the adult programs used it for group. Why not us, I asked. We shouldn’t be second-class citizens.

I approached the chief medical officer, Dr. Otto, and he very reluctantly gave permission. Then I prepped the group saying I’d stuck my neck out and they needed to be on their best behavior. No feet on the furniture or leaving a mess of any kind.

They were great and I made sure Dr. Otto knew that. In all the time I spent at Rogers the kids always surprised me with their potential. Except for one time. During a group, a fifteen-year-old young man was disruptive. I asked him to settle down and when he didn’t, I gave him negative points. He continued. I warned of more points.

Instead of complying, he stood, took the wooden chair he’d been sitting in, hoisted it over his head and threw it. It hit and left a permanent gouge on the wall between me and the patient I was sitting next to. He ran out of the room, followed by an aide. The group was quiet and in shock so I sent them back to the unit and sat for a few minutes alone in the room.  I knew I had to go up to the unit and make an appearance because that’s what I always did after group. And I did.

Such incidents require a special staffing to be scheduled, attended by the entire program team right up to the chief medical officer. At the special staffing the next day, this young man showed no remorse. In fact, when asked if he’d meant to hit me, he said:  if I’d meant to hit her, I would have. I have no idea what he was trying to say but he was discharged that day.

I learned so much from my time at Rogers and especially in this group experience. Perhaps my most valuable lesson was from that helpful rec-therapist who’d taught me something that I carried throughout my career: it’s more important to be respected than to be liked; in fact, if you’re liked you’re probably not doing your job.

 

 

 

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Working at Rogers Hospital

First day at my new job, I’d parked in the back lot; as I walked toward the main building and the door I was instructed to enter, there were screams coming from one of the top floors. A woman was letting out screeches of help me, as if she were being tortured. This was my introduction to my new job at Rogers Memorial Hospital in Oconomowoc. I wondered if this was a sign.

With trepidation, I went inside and found my supervisor. The advertisement had said MSW required. I didn’t have that but applied anyway and was hired as a psychiatric social worker at this private acute care psychiatric hospital.  I was assigned to an adult addiction program.

I hadn’t been too keen on working in addictions (been there, done that) but took the offer as my ticket to relocate close to a graduate school.  Then, within two weeks my supervisor told me the director of the inpatient adolescent-pre-adolescent program wanted to “steal me away” to work in his program.

He’d looked at my resume and felt I had the skills to develop some new programming he had in mind. We had an interview and I was happy to sign on. The in-patient program, housed at the hospital, was run by an out-patient counseling organization, Institute for Motivational Development (IMD).

Referrals for in-patient treatment came from IMD and also from the courts, schools and other counseling services. The typical patients were adolescents with learning disabilities, or ones who’d been expelled from or were failing in school, or had had a first-time encounter with police and/or juvenile court. Then there were the usual drug and alcohol issues, depression and suicide attempts.

Admission was voluntary; the hospital had no locked doors and did not use restraints of any kind. So, the typical patient was not your severe juvenile delinquents or out of control, violent adolescents.

Most often we had kids who were having a tough time that often was short term. The usual length of stay was thirty days but more if insurance allowed. And it often did. Over 95% of them returned home after treatment,

This was my first time working with only private insurance since the hospital did not take Medicaid. It was eye-opening to see these well-heeled kids haul in their boom boxes, fancy clothes and high-tech, expensive items. At admission, they were followed by equally well-heeled parents. Having worked only in the public sector, I was surprised, shouldn’t have been, that these families had the same problems.

The IMD inpatient staff included four PsyDs and two PhDs who were the primary therapists. The hospital program staff included one psychiatric social worker, an addiction counselor, two school teachers, three recreation therapists, various psychiatric nurses and aides.

The program operated on a milieu therapy model, a therapeutic community where patients are encouraged to take responsibility for themselves and others. There is a hierarchy based on achieving levels where peer relationships and peer pressure plays a primary role. The main motivators are positive and negative behavior points and earning privileges.

Any program staff could impose a restriction or reward. Because this was a closed system, we could use more provocative tactics. For example, we sometimes prescribed the symptom.  A patient using not feeling well as an excuse to not participate is made to use a wheelchair and exhibit and explain symptoms of a specific illness. Their frustration quickly rises and they’re usually “cured” in a day or two.

For me, this was a steep learning curve and I was clearly over my head at the beginning. The hospital operated strictly by the medical model so having a lowly social worker actually work with patients was unheard of. I knew I had to prove myself.

Rogers Hospital had been established in 1907 by Dr. Arthur Rogers, a British psychiatrist. Then his protégé, Dr. Owen Otto became the owner and chief medical officer. I worked there in the 1980s and it was experiencing some hard times. Then, in the 1990s, an influential member of the hospital’s board would take charge and bring it to the success it enjoys today.

A Goggle search shows a sprawling campus that is a far cry from the old brick hospital with a few dilapidated out-buildings of my experience. I’m sure that fourth floor locked unit (the only locks there) where I heard those screams on my first day, is no more. And those mentally ill, private pay members of wealthy families are long gone too.

My time at Rogers Hospital was challenging and unforgettable, an opportunity to develop new skills and broaden my resume. While abiding by the institutional structure, I was also given complete freedom when designing programming.

Besides doing psycho-social histories on new admissions and wrangling with insurance companies when an extension was needed, I developed a group with the adolescents two afternoons a week and a parent’s group on Saturdays.

 

Later, I did lectures and groups for other programs within the hospital. An unexpected benefit was that all my hours counted toward licensure.  All in all, this was an invaluable experience that prepared me for graduate school and a rewarding future career.

 

Lesson Learned the Hard Way

He was six years old. I only met him once. He was reserved, guarded, watchful. The epitome of the hyper-sensitive child so common in foster children. It was clear there was a lot going on and this would not be easy. I noticed the marks on his neck. Though it had been eight months since the incident, the marks were faded. Still, they were there.

I first heard about him when my supervisor and the agency Director of Child and Family Services of Upper Michigan called for a staff meeting. Eight months previously, this boy had tried to hang himself twice in a couple of days. After the second attempt, the community mental health clinic arranged a transport to the nearest psychiatric hospital. This was no small task.

We lived in the most western part of Michigan’s Upper Peninsula and there were no psychiatric hospitals in all of the UP. The nearest was at Traverse City State Hospital and that meant traveling across the entire UP and over the Mackinaw Bridge to Lower Michigan. Once treatment was completed, his discharge plan was to return to his home county for follow up services; this included a recommendation for placement in a foster home.

In the staff meeting, I was given the job of locating and overseeing a special needs foster home. We talked at length about the legal and financial issues. When at the hospital, he had been enrolled in SSI and this would ensure payment for aftercare services.

This child had been placed by the Michigan Department of Mental Health instead of the child protective system. So, the usual practice of obtaining a court order to take temporary legal custody had been bypassed.

This family was fully co-operative and unknown to the system with no past history of legal or child protection involvement. This was a child self-endangerment and mental health case rather than a child abuse or neglect case. For that reason, it was decided it would be handled voluntarily.

I’d spent many hours recruiting, training and preparing the foster home and as many hours establishing a relationship with the parents. It takes a long time to gain trust and develop the team that’s needed to help this child. I was sure to be clear that we were a team, no one was the boss and we all were here to help this child.  Everyone was in agreement.

Looking back, I have to ask: what were we thinking? how could we possibly think this could work? The court process seems punitive and sometimes unforgiving so I understood our wish to bypass it. I now see how naïve that was. This work is usually misunderstood and often involves action that goes against what parents want in order to do what’s best for the child. That’s just the nature of the beast.

All it took was the parents learning that the SSI check mailed to them had to be given to the agency to defray the cost of care. Within a week the parents ended the placement. There was no talking them out of it. They knew what was best for their child. And we had no authority.

I was shocked but probably shouldn’t have been. I’d come to know the family was struggling financially and saw how they reasoned this money would be additional income.

Hindsight is twenty-twenty is a common phrase and it sure applies to this case. How bad could a home situation be that a child would try to kill himself?  Looking at the severity of the child’s actions would have told us and we should have listened. Using the full force of the law, we could have protected this child. But we didn’t.

From this, the family disappeared from our view and we’d never know what happened to this child. I learned a hard lesson and came away with a new respect for the power of the law and the need to put a child’s needs above all else.

.

 

 

The Mall

I only met the boy once.  I don’t even remember his name. But his story, I will never forget. I was a supervisor in a big-city child protection unit, so didn’t often meet the children being overseen by my staff of case managers. That was, unless there were problems and a special staff meeting was needed. That’s how I met this boy who was ten and who’d been in foster care since he was five. He was about to mess up his third placement.

His behavior problems were understandable. At age five, his mother had abandoned him at a local shopping mall. It’s beyond imagining, picturing this child, frantic as he searched the hallways for that one familiar person. He was originally placed in a transitional foster home, considered temporary until the court process slowly trudges its way to resolution.

The system had done all it could to locate the mother, a chronic drug user already known to us. It had been, so far, a fruitless process of searching for her or other relatives. By law, each month the system was required to launch an all-out effort by searching public records, running newspaper ads, visiting the last known residence and neighborhood. This would go on for his entire time in care.

Family reunification was always the top priority. But as time passed, the reality of him being returned to his mother faded and his permanency plan was changed to long term foster care. The facts around his abandonment were being handled with velvet gloves by his therapist. All he would say when asked was: “I got lost.” For a child of this age it is imperative to not push the facts upon him until he is emotionally ready to handle it. He had a long road ahead of him.

With his history and age, he’d already been designated unadoptable. He was in a special-needs foster home and that was probably where he’d remain until he aged out at eighteen. Of course, if his current behaviors continued, the system would have to move him to more and more restrictive placements. A group home was probably in his future.

I often shop and go to movies at this same mall. As I look down from the ascending escalator at the activity in this busy and bustling place, I can only imagine that terrible day. I wonder where this boy is and how his life has turned out. He’s an adult by now and I’m hoping he came to terms with this awful and unfair event and has made sense of his life. I hope against hope he has beat the odds by overcoming the dismal statistics so common common to foster children.

Children Protecting a Mentally Ill Parent

July, 2016

The family systems dynamics of dealing with a mentally ill parent are on full display. That’s how and why Donald’s Trump’s high achieving children over compensate for their father’s acting out. They swoop in to protect him, trying to regain control, putting pressure on him to pick a sensible path.

What’s clear is that they’ve been doing this most of their lives. That’s why they’re so good at it. But it may not be enough in this highly charged world of national politics.

Early in the campaign season, I noticed his erratic behavior. There are now a multitude of examples all with an eerie sameness. On this particular night, he began his rally with a few pieces of paper in his hand. No doubt given to him by his campaign handlers hoping to keep him on track.

These talking points were, within minutes, thrown aside leading to his rambling from one topic to another. He never finished a complete sentence before galloping off to another subject with arms swinging wildly and voice wobbling. He’s imploding, I thought.

This was all too familiar. In my working life, I was a licensed social worker and therapist. I kept the DSM (the Diagnostic and Statistical Manual of Mental Disorders) on my desk or in a nearby bookshelf throughout my thirty–five year career. When a therapist, I always worked under the supervision of an MD or PhD for billing purposes and learned very well the long and complex road to diagnosing a personality disorder.

Please note that everything I’m saying about him is presumptive. There has been no diagnose of this individual and there probably won’t be. Personality disorders are especially difficult, both for the clinician and for the patient. Research is still out on the causes but studies point to a combination of genetics, childhood trauma or verbal abuse and negative peer influence.

A general definition of a personality disorder is “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.”  What the textbooks call these “maladaptive behaviors” are deeply embedded into the personality of the individual.

Which explains why Trump seems stuck in a whirl of repetitive and unproductive behaviors. He knows no other way. Sees no other solution. Habitually reverting to old and time tested patterns of behavior have, let’s face it, rewarded him many times. Evidenced by his wealth.  And he’s not the only one. All you have to do is Google ”famous people with personality disorder.” You’ll be surprised. Or maybe not.

Very early in the campaign season, it wasn’t difficult to spot the obvious signs of his narcissism. Features of this personality disorder include: grandiosity, arrogance, lack of empathy, needing excessive attention, being exploitive, feeling entitled.

Add to that, the recent revelation by a journalist (Tony Schwartz, in New Yorker magazine) who is finally saying what he’d discovered. Schwartz followed Trump around for eighteen months then ghost wrote The Art of the Deal. As a result of getting to know him so well, Schwartz calls him a black hole, someone without a soul. I’m sure he isn’t trying to be poetic though his comments are sobering.

Schwartz goes on to call him a sociopath. This is an outdated term but its features are now found in the DSM’s diagnostic criteria for anti-social personality disorder. Those traits include: deceitfulness, impulsivity, lack of remorse, aggressiveness, and reckless disregard for the safety of self or others.

Here may be an individual with two full blown personality disorders.  And while his narcissistic features and his antisocial traits seem to be what we see day in and day out, there has been no definitive diagnosis. Which is why such silence from the psychiatric community. And there won’t and can’t be any official labeling until Trump enters into therapy.

The key to treatment for personality disorder is that the patient continues with the same therapist throughout so that these patterns can be fully analyzed and addressed. Its hard to imagine Trump admitting he might have a problem or might need some help in improving his communication or decision making?  That’s why personality disorders are so hard to treat and why the success rate is so low.

So don’t be surprised at the next spewing of hateful rhetoric, the next demonstration of lack of empathy or his angry diatribe about how he’s being mistreated. Trump will be acting the same way. Until election day. Now I’m the poet!

His campaign handlers will continue to justify his erratic behavior (“He was being sarcastic”).  His VP pick will be expected to “smooth out his edges” and rationalize his gaffs. His children will play out that very important role of the caretaker. News pundits will gleefully revel in the daily newsbytes that build their ratings. Hopefully, voters will come to understand what they’re dealing with before it’s too late.

 

My Worst Jobs

After my 1963 high school graduation, I’d worked for nearly a year at Giddings and Lewis Machine Tool in my home town of Fond du Lac, saving hard for my college future. I spent my work day assembling and soldering circuit boards.

Lay-offs due to budget cuts moved my relocation up a few months. I was excited to get to Oshkosh earlier than expected, happy to get away from my family and get started on my life. I began the job search but with no real skills or a work history, I was only able to get assembly-line factory jobs. It was 1964, the summer of my worst job. It was two jobs actually. This was followed by other bad jobs throughout my college years but these were the worst.

The first one was at Standard Coleman, making television tuners. After a few weeks I felt almost crippled from my blisters and stiff hands. For eight hours I had to pull down an electronic nail gun and punch a part into place. I will never forget the loud mouthed cigarette smoking broads who were my companions on the floor. Some had been there for years.

It was an education in real life to hear them complain in the most colorful language I’d ever encountered about the antics of worthless husbands or boyfriends and their hellion children. My own occasional hang overs didn’t help the situation; I was getting a head start, quickly making new friends and becoming acclimated to the wild and carefree college life. The metamorphoses from my work life to my private life was stark.

When I couldn’t stand the assembly line atmosphere anymore I looked for other work and thought the next horrible job would be better. At Miles Kimble, a printing company, I had to watch personalized Christmas cards coming off a printer and inspect them for accuracy and quality. Boring. And again, surrounded by long time employees, unhappy and hopeless.

What followed throughout my college years was a variety of not quite so awful but still dead end jobs. Store clerk. Waitress. Secretary. Work study clerk. These worst jobs taught me one of the most important lessons of my life. The value of a college education.

 

What Goes Around Comes Around

Everyone knows what the phrase “what goes around comes around” means. It usually involves that arrogant manager or that disloyal friend and our gratification when they finally get what’s coming to them. While we don’t often have the pleasure of seeing it come around, we know in our heart, sooner or later, it does.

I adjusted that phrase when I heard some good news and applied it to how an old idea can come around again in a good way. Maybe that’s the case of Michael Botticelli, recently named but not yet approved by Congress as Director of National Drug Control Policy.

He doesn’t want to be called a drug czar because that harkens back to the decades old War on Drugs and Nancy Reagan’s Just Say No program. That didn’t work, he says, and should be declared over. But he points out, we as a country cannot continue to crowd our jails and prisons with low level drug offenders; their lives are ruined with heavy convictions that make it near impossible for them to get a job, rent an apartment or even vote in the future.

Maybe the combination of over-crowded, expensive prisons and the fact that heroin abuse has reached epidemic proportions, invading all stratospheres of society will make us finally consider another approach. In the long run money spent on treatment and in helping offenders take a new path in life would be more cost effective. At the risk of being labeled a soft hearted liberal I agree with Botticelli and am reminded of my past working in the addiction field.

The recent 60 Minutes segment on Botticelli transported me back to 1983 when I worked in Michigan’s Upper Peninsula. The small hospital housed an AODA (alcohol and other drug addiction) inpatient program using the 12 step model of Alcoholics Anonymous. That was the good old days when drug and alcohol use was considered a disease. At least, the recovering community called it a disease though this concept was denigrated by the general public. Most recently, this has fallen by the wayside as we’ve ramped up the punishment of drug offenders. Substance abusers are now seen only as criminals. And yes, they’ve broken laws but there is much more to the story.

I also say the good old days because back then the treatment community was such a closed network. In order to become an AODA counselor all that was necessary was to have gone through treatment (30 days inpatient) and to be recovering and working a program. I had done neither but fell into the job when my limited hospital social work duties left me time to be helpful in the treatment program. But I was surrounded by suspicion because I didn’t stand up and say I was an alcoholic or an addict and I was the only staff with a college degree.

Daily, I co-facilitated group therapy, beginning with each group member introducing and labeling themselves. Hi. My name is Mary and I’m an alcoholic. Naming it was a necessary way to beat denial. One day, someone asked why I didn’t follow suit. I explained my non-recovering status and then lightened it up with a joke: Hi I’m Karin. I’m a paranoid schizophrenic with narcissist tendencies. We all laughed, I was accepted and we got back to business.

Staff always had lunch together and one day the Medical Director joined us. During our shop talk he said he thought everyone should be abstaining from something. This was the basis of AA, he said. I knew he was speaking specifically to me. I was young and cocky back then and jokingly said I was abstaining from being rich. My comment was not appreciated.

This MD was of the school that believed once you stop drinking all the other problems are fixed too. I’m from the school of co-morbidity, the simultaneous presence of two conditions in the same person. That’s addiction joined with the mental health and just plain difficult life issues that originally led a person to find comfort in drugs and alcohol. For true recovery, it all needs to be addressed.

I’d become friends with one of the counselors who seemed to have some loyalty concerns. She almost guiltily told me I was her first and only non-recovering friend. She also felt she was betraying someone or something by considering any treatment other than AA meetings. But from our many hours of case consultation following group therapy she began to see the connection between addiction and mental health. And also the complexity of changing every aspect of life in recovery.

I came away from that long ago experience with a good understanding of addiction and a respect for the Twelve Step philosophy. Addiction is a chronic illness and needs to be treated as such and that’s hard in our cure oriented world. So, it was with relief I heard the news from Botticelli, backed up by scientific studies that prove how drugs affect the brain. The science supports that addiction needs to be treated not as a criminal matter but as the public health issue that it is.

This is currently close to me since I have a friend whose child is struggling with addiction. After being in and out of jail, my friend’s young adult child has been given the choice of jail time or intensive treatment. This makes me hopeful. Perhaps Botticelli, in AA himself for over twenty years, can return us to sensible and effective results. But will taxpayers and legislators support money spent on long term benefits over short term solutions?

Two weeks later, 60 Minutes read their viewer’s responses to the program. Comments ranged from simplistic to negative. Maybe what goes around hasn’t really come around after all. It’s one thing to have these innovative ideas but quite another to carry them through with our contentious legislature and a doubtful public. I wish Mr. Botticelli my very best. He’s going to need it!

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