Seattle Part 6: the HMO

October, 2014

On my first day, it took me nearly an hour to get to my new job, though it was only about 8 miles distance from my residence. I had to drive down a long, narrow, busy Seattle street through traffic and stoplights, then get on a congested freeway. Traffic moved very slowly across the lake, and there was no other way to get there.

I worked on the top floor of a medical clinic, the local face of a busy HMO (Health Maintenance Organization). The mental health clinic employed around ten therapists, and we were all kept significantly busy. Clients who held a particular insurance were given good rates to see a doctor or a counselor at the HMO, and they were charged a lot of out-of-pocket expenses to see anyone else, thus we always had a long list of people waiting to be seen by a provider. Someone might call in in some sort of crisis and then not be able to see a counselor for six weeks afterward, based on current openings.

I had worked at community health centers before, so I understood the medical model of therapy. I was a clinical social worker, or LCSW, meaning I could get higher than standard reimbursement rates through various insurances, including Medicare and Medicaid, and the company seemed happy to have me there. But this place worked at a much higher pace than anything I had ever experienced before.

First of all, consider therapy itself. A counseling session requires the therapist’s all. There can be no distractions, no phones or music or computers. It’s just the therapist and the patient. There can’t be errant thoughts, or outside stressors, or headaches, or upset stomachs, or sleepiness. The therapist can’t yawn, or stretch, or eat a snack. The client requires one hundred per cent of the therapist’s focus, as well as their clear memories of past therapy sessions, like names of loved ones and therapeutic goals. On top of that, therapists are often dealing with clients who have extreme trauma issues. They hear stories about combat, suicide, rape, abuse, grief, and pain. And when one client leaves, the next is generally waiting, and the therapist can’t still be thinking about the first or she won’t be able to focus on the second.

Doing three or four therapy sessions in a row requires a tremendous effort; doing seven or eight becomes downright exhausting if not impossible. The HMO required more. And doing that day after day, well, it’s not for the faint-hearted. In standard clinics, even busy ones, I became accustomed to doing four therapy sessions, having an hour lunch, then doing three more, with the last hour of the day being reserved for case and progress notes, treatment plans, and correspondence. It was already at a taxing schedule.

But at the HMO, the expectations were much higher. They had competitive wages (about 45 dollars per hour, consistently, on salary) and a great benefits package. But they had their therapists on a very rigid schedule, seeing a patient basically every forty minutes with no time for case notes built in.

A standard schedule might go like this, for one day:

8 am: ten minute staff check-in

8:15: first patient (let’s say an elderly woman with Alzheimer’s whose husband just died)

9: second patient (a teenage girl who recently attempted suicide)

9:45 third patient (a refugee worried about her loved ones in her home country)

10:30: fourth patient (a couple going through extreme marital issues)

11:15: fifth patient (a veteran struggling with PTSD issues)

12: thirty minutes for lunch

12:30: sixth patient (a single mother of four processing stress)

1:15: seventh patient (a woman with a new baby, struggling with postpartum)

2: eighth patient (a mother processing stress over her son coming out of the closet)

2:45: ninth patient (a man referred by his boss for losing his temper at work)

3:30: tenth patient (a ten-year old boy whose parents recently divorced)

4:15: eleventh patient (a woman with borderline personality disorder, recently out of the state hospital following a suicide attempt).

Then, after that, once your notes were finished, you could go home for the day. Every other week or so, there would be a staff meeting of some kind. And every second or third day, a client might cancel or not show up, giving a chance to catch up. But that many patients per day, every day, four days per week, generally meant between 36 and 45 people seen per week. Sessions had to be shorter and more goal-directed, and a failure to adhere to the schedule meant knocking multiple clients back. If a client came in in crisis, very little could be done to manage it without having to cancel another session afterwards completely, and openings after that became hard to find.

I came into the job with boundless enthusiasm. The team of people I worked with were amazing, funny, friendly, and supportive. The agency had great diversity representation, several gay therapists, and a good camaraderie. But as I finished my first week of work, beaten down, grey, and bitter, I began to realize how tired everyone was. It was like working in an emergency room, without breaks, day after day, every day. With an hour’s drive each way.

In Utah, my therapy work had almost exclusively been with LGBT people who were struggling to align their sexuality with their Mormonism. Here, I was seeing people from every walk of life, all struggling with their own sets of problems. The word Mormon wasn’t being brought up anymore, but there was constant depression, anxiety, trauma, grief, and emotional pain. And within two weeks, I found myself unable to offer my client’s my all any longer. Instead of being an incredible therapist, I was becoming a mediocre one, simply to survive the rigorous page.

And with the reality of the new job settling in, Seattle didn’t feel quite so magical. It felt wearying, and expensive. Some cracks in the foundation of my dream life began to show.

And every night, there was the phone call to my sons, who remained far away, and who I missed very, very much.

Mentally obese

brain

Stress wraps its invisible fingers around our insides and begins to squeeze. We don’t notice it at first. It starts out subtly, slithering and silent. It coats our stomachs and wraps around our brains, until one day, we realize our food isn’t digesting properly, our heads ache more often, and we aren’t sleeping well.

Like any kind of weight, stress comes on a spectrum of mild to obese. Mild stress can result in small frustrations, avoidance in relationships, and poor habits and decision-making. Major stress can lead to mid-life crises, abrupt changes in life like divorce and quitting a job, and an inability to rest and relax. Crippling stress leads to constant illness, severe depression, and a perpetual state of dissatisfaction. And people who learn to live with stress begin to think of it as normal and natural.

It isn’t.

Stress is a natural condition for moments, for short durations, during a college final or a work deadline; it is not natural as a perpetual state of living. Being overwhelmed is directly equitable to being mentally overweight or obese.

Mental obesity can also show up in the form of boredom. Humans have a need to be challenged, to be mentally stimulated. A lack of these leads to itchiness, frustration, and dissatisfaction. Education and engagement are crucial to mental fitness and human interactions.

As a therapist, I frequently see clients who are over-burdened by their jobs, or bored with their lives. They struggle with finding any hope in their future, dwelling firmly in the fact that they aren’t happy with their lives or stations now. And when someone is dissatisfied in their jobs, when their talents aren’t being utilized, when they are unemployed, when they feel their boss is constantly breathing down their neck, when they are putting in 80 hours a week and can’t get ahead… when these things happen, humans have health problems and unhealthy eating and exercise habits, they have dissatisfying relationships, they struggle with depression, and they lack purpose and inner peace.

Humans also need to regularly achieve. They need lists to check things off of. The perfect remedy to being bored is to get up and do something; the perfect remedy to being overwhelmed is to choosing one task at a time and completing it.

Another form of mental obesity is extreme debt. We live beyond our means, make big purchases, and charge up credit cards, and then work too much in a constant state of stress while living from paycheck to paycheck and barely managing to pay off the interest payments.

Being mentally fit requires mental discipline, vocationally, financially, and academically.

Somewhere along the line, it was bred into me that there is only one way to be successful. I threw myself into high school, completing difficult homework assignments, sometimes loving the knowledge I was acquiring, and sometimes being so overwhelmed by it that I couldn’t retain the algebra equations and history dates and chemical compositions. In college, I worked full time and would take between 15 and 21 credit hours, and I saw that impossible learning regimen as necessary for adulthood, while sacrificing my emotional, physical, and spiritual health. As a young social worker with a masters degree, I grew accustomed to doing ten hours of therapy for low levels of pay, going home physically and mentally drained each night, and dreading work the next day. Over time, I lost sight of why I got into social into the first place, and began to feel like a cog in a machine that was being aged prematurely.

Around this time, I was receiving steady paychecks, and writing out regular bills, for health insurance, for cable and internet, for electricity and gasoline, for food, for car payments, for medical insurance, for automobile insurance, for cell phone, for tithing, for student loan debts, for college education funds for my sons, and, most overwhelmingly, for mortgage. I would sit down and budget each month and become overwhelmed by the massive amounts of responsibility. Later, after my divorce, this only mounted when child support payments were placed on the top. And I couldn’t even mentally factor in the amounts going toward income taxes, property taxes, state taxes, and federal withholdings. I remember that old pit in the center of my stomach.

I was so constantly overwhelmed by the stress of my job and the responsibilities of my financial debts that I had little opportunity to find things to achieve. I had forgotten the wonderful feeling of finishing a book, the interest I could throw into a research project, or the simple sensation of setting a goal, working on it, and ultimately achieving it. Accompanied by depression, a lack of purpose, and physical weight, the mental stress compounded, feeling like it would overwhelm me and shorten my lifespan.

My mental weight took me much longer to shed than the others. After losing my physical weight, coming out of the closet, grieving my past, discovering my spiritual health, and forming true friendships, I could start to examine my actual stress levels. It was a few more years of maxed out credit cards and working 60 hour weeks before I realized that I was stressed, overwhelmed, and consistently complaining about my financial responsibilities.

My mental health came through exhausting areas:

  1. Making regular time for myself to learn, read, research, and write.
  2. Taking a careful look at my financial situation and preparing a careful plan to relieve financial debt and plan for the future.
  3. Remembering what I love about my professional field, finding a way to make myself happy in my field, and finding a way to make enough money to support myself while doing what I love.

I began organizing my schedule differently. I quit my job and became self-employed, and I began diversifying my services. I advertised. I started with lower rates and then began to charge more. I did regular self-inventory to make sure I was happy along the way. I began limiting my expenses and putting my extra money toward debt. In a year, I was able to pay off one of the credit cards, then my car, then the other cards. I was able to establish a savings account. I began actively learning, and writing about what I learned. I began setting and achieving goals that would have felt impossible years before.

Now, I love what I do. I engage myself intellectually. I challenge and push myself. I take time off when needed, and I don’t let myself get bored. I recognize when I’m overwhelmed and I nurture myself into health again. I budget and plan things out financially. I recognize my needs, and I take care of myself. And, most importantly, I recognize that stress, exhaustion, and boredom are not my natural state; fulfillment, accomplishment, and satisfaction are.

 

(This concludes my writings on obesity. Previous blogs on emotional, physical, and spiritual obesity were previously submitted).

 

 

how to love your job

assembly_line_workers

Don’t hate your job. You spend far too much time there to hate it.

One of the major reasons people seek me out for therapy is due to their job related stress. They hate their jobs, they don’t feel appreciated, they haven’t had a raise in three years, their co-workers don’t like them, they are bored.

The first thing I need to do with clients is help them determine where it is they are unhappy at work with.

I ask the client to rate their satisfaction level with work in four different categories, using a standard grading scale from A+ down to F-, and I ask them to keep their answers focused to today, right now, not how the job could be or how it used to be.

“The first category is Achievement,” I tell them. “A good grade in this category means that you have a manageable work load. You feel challenged, but not often overwhelmed. You are being stimulated without being bored. And you go home at the end of the day having enjoyed what you do, feeling like you are making a contribution.

“The second category is Work Environment. A good grade here means you enjoy your coworkers, have a good relationship with your boss, and that you do well with the politics of the place. This also includes the space you work in, the facility and office, the lighting and location.

“The third category is Sustainability. A good grade here means this is something you can see yourself doing long-term. You recognize that you are growing and changing over time, and your needs at work will do the same. You can grow and adapt within the position, and feel like you are contributing.

“And the final category is Compensation. A good grade here means that you receive a fair and competitive compensation, given your education level and skill level within your position and company; you are making a fair wage given what others in the field are making, and given your responsibilities. In addition, you have a fair benefits package.

“Now in accordance with all of this, of course, is balance with life and relationships, but we are focusing specifically on the job itself. I know attorneys who make an awesome wage, but they work 80 hours per week and burn out quickly. I know people who have created their own catering businesses and love what they do, but they are struggling financially and get bored working at home. I know people who love their job at the fast food counter and do great at it and love their coworkers, but they aren’t paid fairly and have no benefits.

“So look at your job and think about what is missing. If you have an A for compensation, but an F for work environment, that probably isn’t a sustainable job. If you have an A in everything but sustainability, and you know this job is temnporary, you have to find a way to make it work, to grow where you are and plan for what’s next.”

So as you look at your current job, what are your ratings? What is it you are happy with, and what is it you need to look at and problem-solve to get the higher satisfaction ratings you crave? Sometimes that means bold changes, or difficult conversations, or more patience, or further schooling and training.

I know people who stay in the same jobs that they hate for, literally, years or decades.

Don’t hate your job. You spend far too much time there to hate it.