therapy


We tend to think and talk about our jobs in terms of what we produce, not what we do. In some ways, this is misleading. I am a therapist for military families in southern California, so I produce therapeutic conversations with people and clinical documentation to convince the county that I had those conversations. But what would you see me doing if you watched me work for a week? It varies a little but it would look something like this:

19 hours sitting across from people, talking sometimes, writing on a clipboard occasionally

19 hours sitting at a desk, mousing and typing as fast as I can on a laptop

2 hours sitting in my car, driving between offices or client’s homes

30 minutes sitting at a desk, talking on the phone

30 minutes walking to the printer and back to my desk

As you can see, I mostly sit for a living. It’s not what you think when you set out to be a therapist, but that’s the job, and it’s a health sacrifice. The peak of physical exertion in my day is standing up to walk to the printer, and believe me, I value those moments. It’s pretty clear from research that sitting is not a great way to live one’s life: Time spent sitting takes a toll on your health in a way that can’t be made up for by exercising after work. Here’s a pretty good review of some of the research. (It’s a small sacrifice, of course, compared to the sacrifices my clients make in the course of military life. It’s helpful for me to think about it like that–one small sacrifice in return for many big sacrifices.)

It’s also not good for some of the ways I like to be creative, like writing this blog or composing music. I get home and think about sitting down to write, and no thanks. I’ll fly my kite, check for tomato worms, take a walk, help prep dinner, or lie in the hammock. Standing, squatting, walking, lying down, anything but sitting!

Straw bale standing desk

Straw bale standing desk

 

I have experimented with standing desks a bit. At work I can put my laptop on my in/outbox stack and an external mouse/keyboard setup on my briefcase on top of my desk. It doesn’t work for paperwork out in the field–too much stuff to carry around–but works OK at my main office, as long as I have the energy. That’s been the main problem with it at work; I pretty quickly get tired of standing and want to sit down. Standing is not the solution to sitting, but it’s some variety.

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You might argue that the amount of time community mental health therapists spend writing paperwork is unethical, and you would be right in at least two ways: (1) It is an unethical use of tax payer money, paper, and storage space, as much of it is redundant, and (2) it squanders a valuable resource, attention from therapists, on writing, which we are not particularly good or efficient at.

But the worst part for me is that I consider myself a writer of sorts and really care about the quality of my writing, but now spend a large part of my full time week practicing how to write badly. I groan inwardly each time I write something like, “Clinician used psychoeducation about anchoring and adjustment and introduced perspective taking exercises. Client showed understanding of psychoeducation and participated in perspective taking exercises.” And there is no time or economic incentive to make it better.

At least, I tell myself, I did not “utilize” psychoeducation like many of my dear colleagues, but that is small comfort.

It reminds me of why I got out of the small-time freelance record production business. There I was, a songwriter, and the grist for my creative mill was whatever songs someone who could afford my hourly rate brought to me. And those over, and over, and over. Don’t get me wrong–I loved the work and most of what my client’s brought me was good, I just needed to curate what went into my ears more carefully.

The analogy is not perfect, but close. Therapist paperwork writing is not only bad, but emphasizes the least important parts of therapy. A good document of therapy would be more like one of Irvin Yalom’s novels, narrative, interesting, a document of confusion, exploration, courage, inspiration, a document of the development of a mutually beneficial relationship. But this is not what gets you paid. “Clinician challenged cognitive distortions” gets you paid.

And the writing of notes does intrude into therapy occasionally. Occasionally, in session, I have the thought, “How am I going to write this up?” Not a therapeutic thought. Brush it aside, suppress shudder, return attention to client.

One of my supervisors likes to say, “You need to own your charts, you need to love your charts. Your documentation is the only record of what you do.” In an economic and bureaucratic sense, she is exactly right. And I am committed to this career, so I know what I need to do: Fully master the paperwork. Spend as much time as necessary now so that the future me will have perfect case notes, perfect assessments, perfect charts, with no more than the minimal time, stress, and effort spent.  And hope that the bad writing I am practicing makes the minimal impression on my creative brain.

This is a long post, so first the short version. In the last year: I started working full time and am adjusting to that. I’m glad to be working towards my MFT licensure, but uncomfortable about how it pushes my relationships and other projects onto the back burner. My marriage gets better and better, despite this. The company I work for goes out of business so I get part of the summer off, and I get the exact same job (family therapist for US Marines & their families) with a new company.

And for the year ahead: I plan to continue this work, taking good care of myself, dance with Reanna every night, as promised to my friend, Tilke, in her “How to be a Real Artist” workshop, get in best shape in 5 years, and learn how to treat myself and Reanna really really well while working full time.

October: I started my year out at Farm & Wilderness, VT, staffing and teaching a really fun psychology project at Not Back to School Camp. As is traditional, I got really sick, but this time it was from a waitress in Rutland, not someone at NBTSC. I recuperated while visiting Ethan & Susannah, also in Vermont. Back in Joshua Tree, I started working out again (SERIOUS style), planted my first winter garden, fixed some electrical and plumbing problems in my trailer, and started setting up a private practice. In the process of hiring a supervisor, I found out that in California, unlike in Oregon, I cannot do my internship in a private practice. So I started looking for work in a local clinic.

Looking out over Woodward Reservoir from my cabin at Farm & Wilderness

Ethan, cataloging NBTSC lost & found in his library

The famous Quodlibetarian tub

Reanna

Reanna at Playa Del Rey

Ollie, a year ago

Ollie & Pap

Gabe, Damian & Maya on the Hwy 62 Art Tour

Trailer at sunset, looking south

November: I move into a new computer, archive my years of audio journal entries, and learn Sketchup while applying for and getting a job at Morongo Basin Mental Health: providing free, confidential therapy for US Marines, veterans, and their families. In what would become a series of small-town coincidences, a high school friend I hadn’t seen in decades worked there, saw my name on the interview list and sat in on my interview, interjecting stuff like, “Oh, yeah, good answer!” Nice way to interview. The manager of the military program assured me that the our contract was solid for at least two years. That’s about how long I need to get my hours for licensure, so the job sounded good–no chance of having to ditch my clients like I had to in grad school! I spent the rest of the month getting in as much time with Reanna and my family before starting full time work.

Rainbow over the Bartlet Mts

Maya & Ollie in hammock

Ollie helps Nana Honey cook

Me & Reanna

December:  My 93 year old Grandpa Bob gets really sick, and I get really sick taking care of him. I was pretty sure he was going to die. He had pneumonia and had to go on antibiotics for the first time in his life. It took me weeks to fully recover. He eventually recovered, too, but I’m not sure he’ll ever fully recover. He’s been on antibiotics off and on ever since and is progressively less mobile. It’s got me thinking a lot about dying–how I can support the people I love when they start having a hard time taking care of themselves, and how I want to die when my time comes.

I start at MBMH, reading 40 hours a week of protocols. I have Christmas with family in Joshua Tree. My brother Damian starts a weekly evening with family, listening to an integral Christianity lecture and meditation that turns out to be a presentation of integral theory to Christians, rather than Christianity to integral thinkers, but valuable nonetheless.

Reanna & Christina, Xmas

Reanna & Maya, Xmas

Ely, Christina, Pap, Ben, Rebeca, Xmas

Gabe, Ely, Ollie, Christina, Xmas

Reanna, ukulele, heater

Ollie, bundled up

January: I get my first paid vacation ever–one week off, fully paid by MBMH. Weird, pretty nice. I write my first attempt at a comprehensive political statement. Reanna and I start a three-month experiment with a strict “paleo” diet, which mostly means we cut out sugar and grains from our diet. The theory is that human adaptation to grains and refined anything is shallow at best. I also start cooking Mexican food (the paleo-friendly recipes) from Rick Bayless’ Authentic Mexican. I love it. And Reanna loves eating it. I start learning to play Reanna’s ukulele. I play and sing “Amazing Grace” most nights for a month. Fun!

I’m working full time, which I’ve never done. It’s not my favorite schedule. I had to let go of most of my projects. I started building a solar batch water heater in the fall, for example, that is still not finished. The schedule has simplified my life quite a bit. Work all day, spend the evening with Reanna. I gained more respect for my friends who’ve been working full time for decades and still manage to write some music or read books. I’m ramping into a caseload, though, and am seeing seven clients a week by the end of the month.

My endurance training is going great by this point. Mid month I got my heart rate up to 179 bpm without hurting myself. Very exciting.

Smiley and Gallant visit

Reanna in our clean, cold kitchen

Dinner’s almost ready. (Photo by Reanna.)

Grandpa Bob turns 94

Me in therapist costume, with Ollie. (Photo by Reanna.)

February: Full time work continues. I get trained in the Trauma Resiliency Model, which I find very cool and useful. I re-up the trademark on Abandon Ship. I feel sad that I can’t write music with my brothers right now, but have plenty of optimistic plans to do so… Reanna starts designing our future house, another exciting project that I have to watch from the sidelines. I love watching her get super deep into a topic like this, though. She is now the resident expert in passive-solar-optimized-very-small-house design. We start car shopping, too. We need to be independently mobile in Joshua Tree.

Trench. Hose feeding trailer finally to be buried.

Reanna & treehouse near the Mexican border

Ollie, Damian

March: I’m up to 16 clients at MBMH and I’m fighting for mastery of the intense paperwork load. The clinical work is going great. My supervisor is good, I am fully engaged by my clients, and I get to see a good variety of folks–kids, adults, families, couples. The paperwork is fairly unpleasant, though. Mental health providers that get government funding spend a huge amount of time and energy creating and maintaining a paper trail for their work. These clinics get paid based on the work they claim to have done and then various agencies can audit their files and take that money back if a box wasn’t checked or a T wasn’t crossed. I spend my first very late day at work in March, trying to catch up on paperwork. Reanna is not happy.

Highlights: A great lecture by Bruce Perry, planting my first spring/summer garden, endurance training going great (I work out during my lunches at MBMH), meeting the Transition Joshua Tree folks. And Reanna. Reanna is wonderful.

Lowlights: My truck fails smog and I begin what becomes an expensive debacle trying to get it to pass.  I start having sync problems with my Mac that I am still dealing with as I write. I start working on our taxes on weekends. Reanna is Canadian and that makes our taxes super complicated and somehow even though we hired a professional we ended up owing big fines.

Abandon Ship cover art, for the TM folks. Art by Tilke.

Damian & Ollie in old billy goat pen, future garden

Me, just having sunk the garden beds. (Photo by Reanna)

Reanna planting pepper starts

Ollie

Ollie & Reanna take the trash out

Ollie & Reanna rest in the hammock

April: I find out that Morongo Basin Mental Health has decided to go out of business after more than 40 years, at the end of June. That’s quite a shock and less for me than for the many decade-plus employees I work with. At home, our three months of paleo is up and I feel fine, as I have on just about every diet I’ve tried, but it clearly had not solved any of the problems we’d been tracking for the experiment. And I am sick in bed for a week for a third time this year. Reanna’s parents arrive for a month long visit. I don’t get to see them as much as I’d like, but we get in some fun events (like the Morongo Basin Conservation Association’s “Desertwise Landscape Tour” and Transition Joshua Tree’s Water Catchment Workshop), good talks, good swimming.  I get trained in sand-tray therapy by my supervisor, Richard Gray, which I find quite useful.

Reanna preps cholla buds for dinner

Family dinner at Damian & Maya’s (Damian with Bugzooka)

Doug & Kathryn up San Jacinto

May: We get a great little car, a gift from Reanna’s parents. It gets 38 mpg unless we use the AC.  At work, emotions are high and rumors are flying around. I try to avoid it as much as possible. My coworkers are mostly looking for work with great intensity. I decide that I will chill instead, concentrate on my clients, and do what I can to get my job back with whatever company picks up the military contract in the summer.  Meanwhile,  something is eating my garden. My weekends and after work time is often spent critter-proofing.

The highlight of the month by far is meeting my new nephew, Julian.

Julian in sling

Ollie in work gloves

First scorpion of a scorpion-rich year

June: I’m at 21 clients at the beginning of my last month at MBMH. The management has had me continue taking new clients but I’m starting to get nervous about it. It’s starting to look like my clients will have a significant lapse in services, and it pisses me off. I write people in charge at the county and local journalists but no-one can say how long it will take to get the military program back up and running. I know I’m fine. I can look forward to a full season working at NBTSC if things go badly. It sucks, though, that my clients are just getting dumped. It’s screwed up. I just have to set them up as best I can for the lapse and do the tons of paperwork to close their charts. Meanwhile, my co-worker, Jackie, introduces me to Candy Crush, which starts sucking up the cracks in my schedule.

Highlights: Jonathan & Ayako’s wedding in Idaho. Motorcycle safety class with Reanna. And being married to Reanna, of course.

Living room pano: Ely, Christina, Julian, Ben, Rebeca visit

Ben & Julian

North end pano from on top of Reanna’s sewing RV

Ayako & Jonathan, getting married

July: I’m unemployed again, but within two weeks I get interviewed by Pacific Clinics, the company who got the military contract that I’d been working for at MBMH. It looks like I’ll get the job based on the reputation I’d made for myself in that position. That feels good! It means I’ll miss most of NBTSC this year, too, for the first time in 14 years.

Reanna leaves for OR to do prep work for NBTSC and I delete Candy Crush from my phone so I can get some things done: install AC in our trailer, create an outside pantry, build a greywater cistern, make a front step for the trailer, get my motorcycle license, and a few other things. Satisfying. Then I fly up to OR to work the Camp Latgawa session of NBTSC.

Reanna hangs our laundry while I goof off with the camera

Cistern in progress

Julian & me

August: Finish at NBTSC (wonderful, as usual), and spend a few short days in Eugene at an NBTSC leadership summit, then back to Joshua Tree for my last week of unemployment. I completed some last-minute landscaping and plumbing projects, built a dry toilet and installed a weather station, then started training at Pacific Clinics in Arcadia.

At the end of August, Reanna got back from her travels, and we started shutting down all lights and electronics at 8pm and just hanging out until going to bed. This was lovely. We usually laid in the hammock outside, talking and looking at stars. The desert summer evenings are really, really nice. Especially with Reanna.

My advisee group, NBTSC Camp Latgawa

Ely & Julian before dinner

Reanna & Ollie, downtown Joshua Tree

September: I start making contact with clients and by the end of the month I’m back up to 7 clients. This is exciting, and it’s nice to be working with some of my old co-workers from MBMH, and the new crew at Pacific Clinics is an entertaining bunch. Working full time again limits what I can do in terms of projects, but I manage to put a new roof on the old goat pen/the new outside pantry, go visit Quail Springs permaculture farm, and start building a new composter with my 2-year-old nephew, Ollie.

At the end of the month, I have my first birthday at home in many years. Usually I’m at camp. It’s nice. My family threw me a little party and I’m glad to be here, even though I miss my people at Farm & Wilderness.

Yes, Ollie wants to help build the composter!

Rain Event, 29 Palms

With Reanna & ocotillo, on my 42nd birthday.

Sometimes I imagine being able to visit myself in the past, usually my anxious or sad teenaged self, and wonder how I could be the most helpful to him and the rest of his-future/my-past selves. One thing I like about this fantasy is that it reminds me how lucky I am. There are people who would probably want to tell their young selves something like, “It’s very important that you do not use X drug because it will ruin your life,” or “It is never OK for a romantic partner to hit you. Dump them and go immediately to the authorities.”

I usually imagine delivering a convincing version of, “If you are scared or sad, it’s because scary or sad stuff is happening, and that’s the way life is. Know, though that this all works out. Your next several decades are much better than you can imagine. Yes, there will be scary and painful stuff, but remember that it works out great.” I can vividly imagine beaming at my young self, delivering this message.

There is something comforting about this fantasy, like my young, internal Nathen benefits from hearing it. This led me to taking the question a step further: Given my life so far, what might my 80-year-old self want me to know now? I like to imagine my old, wrinkly self beaming at me, saying, “This works out even better than you can imagine…” As far as I can tell it is likely true, and it is quite calming to imagine.

It strikes me that this is something like what I do in my therapy work. Yes, there is the occasional need for advice, but the biggest part of what I do is let clients know with my mind, body, and soul that their current struggle is a small, if poignant, part of their life story. I welcome their sadness, anger, and anxiety as appropriate, given the circumstances, and I have confidence in their goodness, their strength, their resourcefulness. I try to know and show that this works out for them. It can and they deserve it.

Some of my oldest memories are of lying in bed, late at night, wishing I was asleep: sleep-onset insomnia. I’m happy to say that I have largely overcome this malady. I have a sizeable bag of tricks to help me out with it (read about them here), the most important of which is having gotten over my fear of insomnia, which had become the primary source of sleeplessness. For the last several years I’ve had trouble getting to sleep just a few times a year.

For the last couple months, though, I’ve been experiencing “terminal insomnia,” AKA waking up too early and failing to fall back asleep. Most of my tricks don’t apply here. It sometimes helps to stay in bed until my alarm goes off–occasionally I will fall back asleep. Sometimes cuddling helps, too, but I’ve found nothing consistent so far. It’s become a problem: I’m getting married next week and sleep debt tends to make me clumsy, grouchy, and stupid–not the way I’d like to show up for this event!

So I complained about it to my therapist today and he gave me his hypothesis: I am chronically and habitually productive. Productivity is a way of life  for me and it’s infiltrated my groggy, should-be-going-back-to-sleep mind. He is right. I am on the go all day. It never occurs to me to slow down, much less take a nap, and that was exactly his prescription:

“I wonder what would happen if you cultivated a habit of trying, even to a ridiculous degree, whenever you noticed being really tired , just saying, ‘OK, I’m just going to lie down. I’m just going to quit what I’m doing and lie down.’ Even if it seems indulgent or incovnenient. Just ‘F*** it. I’m lying down, I’m closing my eyes, I’m relaxing. If I sleep, I sleep–it doesn’t matter. I’m just going to relax.’ Look at your tiredness as a sort of enlightened messenger, giving you the gift of saying, “Stop it! Stop working so hard. Just lie down right now and be irresponsibly lazy. Just lay out.’

“And you’ll have to deal with the resistance in you too. The well-trained hard, hard worker in you will say “Now’s not a good time… maybe later,” and the challenge is to say “F*** you. I’m not buying it. I’m lying down. For at least five minutes I’m going to lie down, deep breath, deep relax, and invite myself to doze if it happens.

“It’s the next logical progression of getting over the fear of insomnia: The next step is getting over the fear of being tired. OK, I’m building into my lifestyle being tired and loving myself in my tiredness. If I’m tired, I lie down. Why the hell not?

“I want you to take it on as a spiritual practice. Seriously. A spiritual practice of just interrupting productivity as often as possible in order to be lazy and relaxed and tired and just let the earth hold you up. When you lay down, experience the earth holding you up and receive that kind of support. You are a very diligent, principled and hard-working fellow, Nathen, and we have noticed. We got the message. You’ve got that covered. You’ve acheived that already and can let your pendulum swing back in the other direction.”

He’s right that it won’t be easy. As I’ve been writing, I can feel the familiar tiredness in my face and arms, weighing me down, and I’m choosing to write instead of lie down. Well, maybe I will go lie down and finish this later…

When I find myself in the presence of a new very smart person, my favorite question to ask is,”What is the most interesting question in your field?”* It both makes for great conversation and expands my sense of the envelope of human inquiry.

If you have an idea about the most interesting question in your field, I’d love to hear about it in a comment below. If you are the kind of person who creates and publicizes websites, though, what I’d like even more is for you to create a wiki-style site where folks can go, create a forum for their field or sub-discipline, and propose and vote on most interesting questions. This could generate what I want to look at: a home page that is a self-updating outline of what professionals believe are the most interesting questions in their field. If you want to go whole-hog, you could also let them vote on and link to what they believe are the best pieces of research on their question to date.

And since I posed the question, I should probably tackle it for my own field… I am a couples and family therapist, and I propose that the most interesting question in my field is, “What are the precise mechanisms of therapeutic change in couple and family systems?” In other words, how does therapy work? We know that it is helpful in most cases, and we have endless models and speculations about how it works, but virtually no evidence about the mechanisms of change. The best research I know about on the topic is the qualitative, two-part, “What Clients of Couple Therapy Model Developers and Their Former Students Say About Change,” by Davis & PiercyEdging into that territory from another angle is the research summarized in Gottman’s The Science of Trust.

*I stole this question from very-smart-person Ethan Mitchell.

I gave my first interview a few weeks ago to Peter Kowalke of The Unschooler Experiment. We spent a week together at an east coast session of Not Back to School Camp, but never had a real conversation before this one. He turned the interview into a podcast about my therapy work with unschoolers. I was a little nervous about talking on tape and came away thinking I had rambled too much, but Peter edited it well and I think it came out good. Click on the photo to go to the podcast:

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