40 Years - Chapter One - Take The Client Where They're At

If you asked me “what’s the most important thing you learned in your Social Work graduate education” I would say it was Dr. Maureen Didier telling me, “Take the client where they’re at, take the client where they’re at, not where you want them to be, not where you think they ought to be, where you think they should be, take the client where they’re at!”

I had Dr. Didier for three out of the four semesters of our 64 credit hour Masters in Social Work program. I, as a young person, had some disdain for my graduate work become it wasn’t pure social science but applied social science with lots of methods courses. And so I held a lot of my education in those days in some contempt I am embarrassed to now say because it has served me very well.

Outside of class I would mock Dr. Didier and say to my fellow students, “Can you believe that this is what passes for graduate education, her standing up there saying ‘Take the client where they’re at. Take the client where they’re at” in a high sing song mocking voice. And yet 40 years later I have Dr. Didier on my right shoulder whispering into my ear when I am frustrated, when I am going too fast with a client, when I find myself imposing my values, and hopes and dreams and preferences and desires onto the client, “David, take the client where they’re at.” And I slow down, step back, listen more deeply, try to understand where the client is coming from and what the client wants,  and I realize that things always go better.

I find the maxim, “Take the client where they’re at” to be just as important and just as good advice in my personal life as in my professional life.

After 40 years, I thank Dr. Didier and marvel at her wisdom. I laugh at my vanity, egotism, condescension, and am ashamed to tell you that I laughed and mocked her.

I don’t know where she is, or even if she is still alive. I think she has probably died. I thank her every day and say a prayer of thanksgiving for what she taught me. I am sorry for mocking her. I hope she would forgive me for not appreciating her wisdom when I was younger.

I pass her wisdom along to you and suggest if there is never anything else you learn in your Social Work education and/or practice or life, remember Didier’s dictum – “Take the Client Where They’re At.” It will serve you, your clients, and those with whom you are in relationship very well.


40 years and counting #1

I realized the other day that on October 31, 2008, I will have been a Psychiatric Social Worker for 40 years. I am thinking to myself - "What have I learned in all that time that might be valuable for me to reflect on and remember and might be of value to others?" So I decided to write a book. And part of that book writing effort I am going to put on this blog. I entitleing the book, at least for now, 40 years and counting. (If you have better titles let me know.) So, if you want to follow the progress as I write and comment on this work in progress check in regularly for the latest installment.

Here is installment number 1

On October 31, 2008, I have been a Psychiatric Social Worker for 40 years. I started my career at Kings Park State Hospital in Kings Park, New York half way out on Long Island just over the Nassau County line into Suffolk county on Long Island’s north shore. I started on October 31, 1968 as a Psychiatric Social Worker Trainee II.

My supervisor Fred Ironside asked me where I wanted to work and I told them on the Child and Adolescent unit and they put me in the geriatric building with 900 geriatric patients and where they hadn’t had any Social Worker services in over 1 ½ years.

I learned many things there but most of all to love and respect old folks.

This book is about what I have learned as a Psychiatric Social Worker over 40 years of practice. It is going to be a lot of very personal things. You may find a lot here that you disagree with or even find offensive and that’s OK. Part of practicing any profession is not what you learned in your professional training or what the textbooks say, but how you applied what you learned and made it work for you and made sense out of it.

Social Work is a very personal profession. A good Social Worker uses his/her personality as  their primary professional tool. Most of Social Work depends on developing a helping relationship with individuals, couples, families, groups, communities and representatives of all kinds of organizations, companies, agencies and governmental entities.

The key to good Social Work is the effectiveness of one’s interpersonal skills which depends on one’s emotional intelligence. It also helps if one is smart. It also depends on humility and knowing what one doesn’t know and being able to recognize one’s ignorance, incompetence, and asking for help. Without that humility you are dead in the water and would do better in some other profession or career.

I have taught over the years at various colleges as an Adjunct Professor teaching Social Work courses, Psychology, and Health Education. I have worked over my career as a clinician as well as a manager and administrator and so I bring the experience of several life times to my teaching. Angela and I were married 35 years and have 9 children so I always worked at least three jobs often 60 – 80 hours per week and sometimes more. With all this experience, I find myself saying things to my students like “I know this is what it says in the textbook, but let me tell you how it really works.” Of similarily, “I know this is how it says in the textbook to do it, but this is what it really looks like and feels like as you try to bring those principles, ethics, practices into application.”

Am I cynical? Yes. Do I passionately believe in the field and the value of the profession? Yes and more so with every passing year. I have been abundantly blessed to have entered into the profession of Social Work and my life has been richly benefited both professionally and personally. To be able to earn my living and get paid for something I love doing and passionately believe in is the greatest life any human being could have.

So, enjoy my stories of my 40 years of experience. Hopefully you will find them entertaining, maybe enlightening, and above all else, it is my wish that you find them useful as you go about living your own life and finding your way in the world.

I will be tagging these entries as "40 years"


Smoke-Free Policies Prove Effective

No smoking Reuters HealthDay reported on July 1, 2008 on a study in the July 2008 issue of Lancet Oncology that found that smoke free policies work.

It has taken a fight in many places to get smoke free policies in place. There have been many obstacles and barriers. It is always difficult to overcome addiction and to give up the profits that accrue from them. It turns out that the Public Health professionals were right all along.

Here is a snippet from the Reuters article:

Smoke-free policies are extremely effective at reducing smoking rates, exposure to secondhand smoke, and even smoking-related heart disease, new research shows.

The report, by an International Agency for Cancer Research working group, also found smoke-free rules don't affect business in restaurants or bars.

The researchers analyzed available evidence and found:

  • Implementation of smoke-free policies substantially decreases secondhand smoke exposure.
  • Smoke-free workplaces decrease cigarette consumption in continuing smokers.
  • Smoke-free policies decrease respiratory symptoms in workers.
  • Smoke-free policies don't decrease business in restaurants or bars.
  • Voluntary smoke-free home policies decrease adult and youth smoking and children's exposure to secondhand smoke.
  • Smoke-free workplaces decrease adult smoking rates.
  • Smoke-free policies decrease tobacco use in youths.
  • Smoke-free legislation reduces rates of heart disease.

MedlinePlus: Smoke-Free Policies Prove Effective.


Coronary Heart Disease Deaths And Decreased Smoking Prevalence in Massachusetts, 1993-2003

Cigarettes According to a study published in the August, 2008 issue of the American Journal Of Public Health in the ten years since the implementation of the Massachusetts Tobacco Control Program in 1993, the smoking prevalence rate dropped 29% and the coronary heart disease mortality rates dropped 31 %  with 425 fewer deaths which resulted in 3,365 extra life-years.

As a public health intervention, controlling tobacco use in populations has big health dividends. However, they raise interesting moral issues such as should people be able to engage in life damaging behaviors such as smoking? Should this be an individual choice or should governmental intervention make such choices difficult?

Here is the abstract from the AJPH.

We used the previously validated IMPACT coronary heart disease (CHD) mortality model to estimate the CHD deaths attributable to reductions in smoking prevalence following the introduction of the Massachusetts Tobacco Control Program (MTCP) in 1993. A 29% and 31% decline in smoking prevalence and CHD mortality rates occurred, respectively (from 1993 to 2003). A total of 425 fewer CHD deaths, which generated approximately 3365 extra life-years, were attributable to decreased smoking prevalence. With these results in mind, a comprehensive tobacco control program should be sustained and supported.

Coronary Heart Disease Deaths And Decreased Smoking Prevalence in Massachusetts, 1993-2003 -- Kabir et al. 98 (8): 1468 -- American Journal of Public Health.


Statins Associated with Less Cognitive Decline

Dementia I take my simvastatin every night before I go to bed and my mind is like a steel trap and I'm 62. Is it the simvastatin or am I just a sharp guy? I have a little CRS (can't remember shit) though. My colleague and friend, Garry, says its "nominal aphasia". While I can't remember the person's name I always remember what my problem is called.

The study appeared in the July 28,2008 issue of the journal, Neurology, and the summary appears on Physician First Watch on July 28, 2008. Here is what the Physician Watch article says:

Elderly people on statins showed a lower rate of cognitive decline than those not taking them, according to a prospective observational study in Neurology.

Researchers followed a population-based cohort over 5 years, examining the participants' medicine cabinets for prescription drug use and measuring their cognitive status annually. The cohort comprised nearly 1700 Mexican American subjects, all over age 60, roughly a quarter of whom took statins at some time during the study.

By the end of the study, those who'd taken statins were about half as likely to have developed either dementia or cognitive impairment without dementia as others in the cohort.

The authors point out that there have been no primary prevention trials of statins for dementia. Writing in Journal Watch Cardiology, Joel M. Gore says that such studies are needed "before statins are routinely deployed

I wonder if John McCain takes Statins? Watching him speak has left me with the impression that he has come cognitive difficulties.

Statins Associated with Less Cognitive Decline - Physician's First Watch.


The boot camp of life

Boot camp In the book, Daily Afflictions, Andrew Boyd uses many concepts and phrases which are eye catching. One such phrase is "The boot camp of life." In the glossary at the back of the book, Boyd, defines this phrase as - "A traditional child-rearing practice in which the child is trained to handle the dysfunction of adult institutions by being relentlessly drilled in dysfunction by his own family." p. 91

As a therapist as well as in my personal life, I am continually struck by the observation that parents don't deny the dysfunction that their children are subjected to but excuse it as being good for them. There are many phrases such as "what doesn't kill you will make you stronger." "Compared to what I have to endure this is nothing." "He better get used to it now so he is prepared for real life." etc.

I have referred to this as the callous theory meaning that parents excuse the abuse that their children suffer as "toughening them up" so that he/she can better deal with abuse later on in life.

I don't think there is any research evidence to back up this callous theory - that abuse and dysfunction earlier in life makes one more resilient later on in life. In fact, the research evidence appears to be the opposite, that abuse and dysfunction earlier in life is a risk factor for problems later on in life.

This callous theory is part of what John Bradshaw named "poisonous pedagogy".

One of reasons that my wife and I decided to homeschool was to protect our children from the institutional dysfunction that occurs in Middle school. Schools are bureaucratic institutions which are very self serving and subject children to dysfunction which mirrors the dysfunction in families, - bullying, cliques, playing favorites, mind numbing worksheets and busy work, obedience and compliance with requirements that are artificially imposed, loss of control over one's own life, disrespect, and fear being used as a motivating factor.

In the criminal justice system, boot camps began being popular 25 years ago where rigorous physical exertion and browbeating inmates for compliance was thought to  bring about compliance, obedience, and self discipline. Research has found that boot camps don't work. The belief that dysfunction and abuse is somehow good for people is similarly erroneous. Whilte the boot camp of life is an eye grabbing metaphor, one would do well to question, deconstruct, and dismiss this idea as beneficial for facilitating the development of a high quality, healthy, happy life.


Suicidal soliders is not so much a mental health problem as a spiritual crisis

Suicidal soldiers Reading about the increased incidence of sucides in the military and the huge numbers of soldiers with PTSD has gotten me interested in something which very few people in American society talk about and that is what Dr. Rachel MacNair calls "Perpetration-Induced Traumatic Stress", PITS.

PITS is the anguish and guilt which one human being feels when he/she kills another human being. This has been increasinly labeled as a mental health problem which it surely is, but even more, it is a spiritual problem in my view. All the mental health treatment in the world, and all the medications cannot absolve the guilt induced by the willful, deliberate killing of another human being.

There is a good article that attempts to describe this problem which was published in the Seattle Times 4 years ago on July 21, 2004. Here is a snippet:

Tucked behind a gleaming machine gun, Sgt. Joseph Hall grins at his two companions in the Humvee.

"I want to know if I killed that guy yesterday," Hall says. "I saw blood spurt from his leg, but I want to be sure I killed him."

The vehicle goes silent as the driver, Spc. Joshua Dubois, swerves around asphalt previously uprooted by a blast.

"I'm confused about how I should feel about killing," says Dubois, who has a toddler back home. "The first time I shot someone, it was the most exhilarating thing I'd ever felt."

Dubois turns back to the road. "We talk about killing all the time," he says. "I never used to talk this way. I'm not proud of it, but it's like I can't stop. I'm worried what I will be like when I get home."

The men aren't Special Forces soldiers. They're troops with the Army's 2nd Armored Cavalry Regiment serving their 14th month in Iraq, much of it in daily battles. In 20 minutes, they will come under attack again.

Many soldiers and Army psychiatrists say these constant conversations about death help troops come to grips with the trauma of combat. But mental-health professionals within and outside the military point to the chatter as evidence of preventable anguish.

It is very difficult for us as a nation to face up to the immoral and illegal war which we have perpetrated and are paying for which was based on lies and deceit by our government, let alone for our soldiers who have actually killed other human beings, civilians, women, children, for reasons that are not clear at behest of psychopathic and irresponsible leaders. What does this killing do to a person's soul other than lead to anguish, revulsion, self-recrimination, and too often self destruction in one form or another.

Families of these suffering souls have wanted to be proud of their relative's service and to believe it was for a good cause, but the truth does not match the delusion. The inability of people back home to "understand", let alone accept, the truth, leaves the suffering soldier even more isolated and tormented.

What is the answer to the spiritual suffering? The truth and repentence. Will McCain or Obama lead us there? I doubt it very much unless we as a country are willing to face our demons and admit that what has been done in our name is wrong. Witnessing the suicides and PTSD of our returning soldiers fortunately or unfortunately won't let us ignore or forget the heinous acts they have been asked and compelled to do in our name. The guilt belongs to us all not just to the perpetrators, but they are the more active participants while we just watch, cheer them on, and lie to them telling them they are doing grand, honroable, and glorious things when deep in their souls they know better.

I intend to write more on this topic so I am adding a new category to my blog today called Perpetration induced stress.

Nation & World | Soldiers trained to kill, not to cope | Seattle Times Newspaper.

 

Suicide of troops only one symptom of National spiritual dysfunction in the U.S.A.

I passed a car this morning that had a yellow ribbon on it which said "Support The Troops", and a decal on it which said, "Thank them for their service protecting our country." And I wondered to myself how do you thank people who are engaged in immoral and illegal activity of waging a pre-emptive war for a corrupt government than has waged war based on lies?

The Nurmeburg trials after World War II developed the principle that "just following orders" does not absolve a person from legal and moral guilt. The fact is that many of our troops are engaged in illegal and immoral activities, activities which they cannot justify to themselves or to others and so when they return home "from duty", from engaging in these activities they are killing themselves in greater and greater numbers.

Our chauvanistic and patriotic jingoism does not help these soldiers at all because they know what they did, and they are not proud, and they cannot say anything when they are being falsely adulated, and continued to be lied to that they have done brave and noble things.

What our soldiers and our country needs more than anything is the truth, because it is the truth that sets people free not lies in spite of what the current administration tells us.

When American soldiers choose suicide over life back in the U.S.A. that should tell us something. They know something we don't know and that is that our spirit is seriously broken and corrupted as a nation.

Truth, honesty, repentence, forgiveness, exoneration, reconciliation are badly needed in our national soul and the prophetic leadership is sadly lacking. Until it emerges our returning troops will continue to suffer and kill themselves.

It is a mistake to view the suicide and psychiatric crises in our returning veterans as mental health problems alone. At the core they are spiritual problems, and Americans as a whole share a spiritual responsibility for the state of our nation's soul. The suicide of our soldiers is only one symptom of serious spiritual dysfunction of our country.

James Jenkins was a Marine who served two rotations in Iraq. He became increasingly agitated and dispairing over the 212 people he states he killed and he told his mother he didn't understand why he was there. It seems that a very promising, bright, hard working, intelligent young man joined the service "for college money" and "to serve his country" only to find out that the "service" involved unspeakable activities that he would rather kill himself for than have to live with. It is a very sad commentary on how the current administration and our country has exploited its youth and their potential for very dishonorable , deceiftul, and destructive policies.

The blood of James Jenkins, the 212 people he killed, and the thousands and millions who have suffered because of this tragic policy falls on George Bush and his ilk and all the idiots in this country who voted for them.

Video lasts 7: 16


Pennsylvania Injuries Rise After Repeal of Helmet Law

Motorcyling I have argued this point with various people over the last few years that motorcyle helmets and bicycle helmets save lives and traumatic brain injuries. Only 20 states require motorcyle helmets, New York where I live, being one of them. Two years ago, Pennsylvania stupidly rescinded its helmet law and guess what? Right. Head injuries and deaths have gone up dramatically. Here is a snippet from the June 11, 2008 Reuters HealthDay article based on an article which will appear in the August issue of the American Journal of Public Health:

In the two years after Pennsylvania repealed its universal motorcycle helmet law, there was a 32 percent increase in motorcyclist head injury deaths and a 42 percent increase in head injury-related hospitalizations, a University of Pittsburgh study says.

The state's universal helmet law was repealed in 2003. Currently, only riders under age 21 and those with less than two years' experience who haven't taken a safety course are required to wear helmets.

The researchers analyzed data from the state's health and transportation departments for the years 2001-02 and 2004-05 and found helmet use by motorcyclists involved in reported crashes decreased from 82 percent to 58 percent in the two years after the helmet law was repealed.

While the head injury death rate increased by 32 percent, there was no increase in the non-head injury death rate.

Along with the 42 percent increase in head injury-related hospitalizations after the repeal of the helmet law, there was an 87 percent increase in the number of head-injured, hospitalized motorcyclists who required further care at facilities specializing in rehabilitation and long-term care.

Total acute care hospital charges for motorcycle-related head injuries increased 132 percent in the two years after repeal of the law, the study found.

I was talking to a young 16 year old client of mine who is a true libertarian and who advocates for goverment to stay out of people's lives and let people to do as many stupid things as they like such as drink alcohol, drug, have promiscuous sex, ride motorcyles helmet free, etc. His point is that it would be an exercise in social darwinism, that is, the stupid will die young and not reproduce. In a way I think he has a point. It could be that New Yorkers are a little smarter when it comes to public health than Pennsylvanians. Certainly our auto insurance and health insurance companies prosper while Pennsylvanian insurance companies are paying the price of stupidity as well as individuals and their families.


MedlinePlus: Pennsylvania Injuries Rise After Repeal of Helmet Law.


Psychologists engage in torture and war crimes

On Friday, July 18, 2008, Amy Goodman, host of Democracy Now, interviewed Jane Mayer, the author of the new book, The Dark Side, about the role that psychologists, and the APA played in torturing prisoners in the so-called "War On Terror".

It seems that America has lost its way under the Bush administration and has engaged in war crimes. Americans have lost their ideals under this administration as they have watched their leaders justify and engage in policies and behaviors that  disregard human rights, dignity, and justice.

It seems ironic that a President who engaged in illicit sex in the White House is impeached, while a President who is an international war criminal is ignored. What has happened to the American people?

Amy Goodman's interview is well worth listening to or watching. You can do so by clicking on the link below which will take you to the show on the Democracy Now web site.

Here is part of the interview. It lasts 8:29


Democracy Now! | July 18, 2008.