I woke up to a grey Saturday, the sky a pane of dullish ashen, the sound of planes going towards LaGuardia or Kennedy, descending below the cloud line as they approach their destinations. The street is quiet from the dining room table at which I write, the constant “hum” from highway 297, a block away, only heard from the other side of the apartment. In the house, all sleep and I get up to complete some notes, an unending and infernal part of my job, the clichéd yet so apropos “bane of my existence.”
I am a clinical social worker at a hospital’s mental health clinic situated in Brooklyn, a non-profit, still somewhat independent; a unique institution with no formal affiliation. This makes little difference, I know, for I speak to other clinicians who practice at other hospitals, private, public and city run. It matters little. We have all become assembly line workers in the factory of mental health.
I completed these short three notes, from a week before, lest they “lock.” When they lock, it sets in process an obligatory reminder email from one of the managers, “cc’d” to at least five other people, all supposedly important, all laden with titles full of acronyms whose meanings are unknown to all but the proprietor, yet add gravitas to a name and a role in the factory. As I was writing, after a well-rested night, with the day full of promises ahead of me, I realized that the content, the depth and the writing were unlike that of most other blurbs that provide a summary of a person’s mental status. No hasty, badly composed sentences, repeated ad nauseam, a sort of rubber stamp to ensure that the hospital is reimbursed for a patient’s visit.
As a clinical social worker, I spend 30 or 45 minutes with individuals and using various methodologies I attempt to bring solace, clarification or just provide some company to the many troubled souls that struggle to rid themselves of daemons, bad choices and bad marriages, mean children and mean parents, poverty, and racial, gender and legal oppression. I am humbled to be the trustee of horror stories and strive to lighten the load of trauma and misery. Each individual a universe, unique and rich in diversity and exceptionality, each encounter a rich tapestry of interwoven tales, brought to life by their words, at times almost poetic and lyrical, most often devoid of joy, devoid of life. I put much effort into comprehending and grasping the fullness of the person’s potential as well as their possibilities. I toil to fulfill the other responsibilities, the bureaucratic drudgery, the clicking of endless buttons on a form, the phone calls, the emails, the forms.
I am a unionized clinical social worker, paid to work 35 hours a week, with two 15-minute breaks and a one-hour lunch. That’s the hypothetical, the agreement between my union and the hospital. Yet I take no such small breaks, eat a harried and hurried lunch when I eat at all, and carry a load of on average 100 people, for whose lives I am partially responsible. I see them at my clinic but inevitably bring work home. At the facility, I put in at least 50 hours and live with a constant dread of not having clicked a button, of not having made another phone call, of overlooking the sadness in someone’s eyes, of not fully paying attention, of not having been totally and completely present and mindful. I write rushed notes, just the obligatory, no depth, no conveyance of the interaction that just transpired. My mental health and that of many of my colleagues becomes compromised, the risk of burnout or empathy fatigue is high, yet the machine hums along. Every day, every hour, I strive to provide the best clinical and empathic care. And yet, I am always behind on paperwork, risking disciplinary actions. No one speaks of the quality of the work, as it’s all about quantity. I am privileged to work with a mostly exceptional group of professionals, and I love what I do. I have also been witness to shoddy and rushed work, clients who deserve better but don’t know what to expect.
The turnover rate in psychiatry is very high, where constancy is most needed. We appear surprised when sequential Wars on Drugs and on Depression and on Obesity are wars lost. We do not invest in prevention and we run the workers into the ground. Mental health work is not valued in this city, it is not valued in this country. Yet, this is a profoundly unwell society and the signs abound. Mental health cannot be run on Fordism, with increased production, in less time and with less resources. There are plenty of resources, but they are all going to the pharmaceutical companies who charge 10 times as much for the same medications in this country as they charge in the European Union and other parts of the world. We have vice presidents of vice presidents, subdirectors of subdirectors. We have more bean counters than we have beans. We are overseen by so many agencies that most clinicians do not know who does what, when, and how. Those, too, are profligate with acronyms.
Our mental health system is very ill, and the people who most suffer are those who most need it. We are not just individual agents of change but if we are to be effective in any way, we must get out in our communities and be social agents of change. It is our responsibility to challenge those special interests with the armaments we have. Systems knowledge and systematic challenge to the powers that be must be part of our tool set. Moral courage and outrage are required as is the capacity to flex our mental and physical muscles. It is possible and not quixotic.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.