In a few hours, NEFESH will be hosting an event on the state of clinics today, so it seemed an apropos time to put this in writing. For the reader’s information, I am a Director of 2 clinics with The Jewish Board.
If I may indulge the reader with a few beginning caveats:
To state the patently obvious, the world is a messy, difficult place, most decidedly because people themselves are messy. The more people congregate themselves into organizations, the messiness factor expands exponentially. People have maddeningly different personalities, and, when people organize, they inevitably establish norms, rules, and even regulations. It is an entirely normal human drive to flee the messiness of organizations and seek the solace of being one’s own boss. I most certainly do not begrudge any individual his or her choices in lives and careers, but I would suggest that there is something highly valuable, maybe even noble, in learning to cope with and appreciate messy organizations. Organizations and collectives are where great things can happen (also potentially terrible things!). While organizations are messy and maddening, they are also far more powerful vehicles for positive change than are individuals.
I have heard, from bitter former clinic workers, that “they only care about…(insert requirement here, i.e. treatment plans, session notes, billing, etc.). I have worked in organizations for my entire 20 year career. I have met many people, many admirable, some not much at all. I have NEVER met a person who didn’t care about people, and who only cared about paperwork. This often heard critique of clinics suggests exactly what is potentially gained in the clinic setting, and what is lost by fleeing it. Namely, the development of appreciation for nuanced thinking in coping with the competing interests of many different stakeholders and societal influences. It is all too easy to dismiss those who are struggling to balance complex influences with the fantasy that only I truly care. The reality is far more nuanced, and working in clinics should help the therapist learn to appreciate this nuance.
Another frequent complaint about clinics is the presence of demands and regulations. Treatment plans, continuous quality improvement projects, clinical scales, long assessments, etc. To return to the “organizations are messy” point, regulations are an extension of this messiness. Regulations, by definition, are blunt instruments. While they may be well intended to help, they do not always help. ACS calls do not always protect children. Nursing home regulations do not always help the elderly. Even criminal law does not always help the public. Regulations, like the people that write them and the systems they operate in, are imperfect. Still, more often than not, they are, on the whole, for the benefit of the public. Maybe developing a treatment plan is not really clinically indicated for every individual, but it seems to me that it is for a whole lot of clients. Shouldn’t every experience of therapy have some mutually agreed upon road map or plan? Shouldn’t we have some sense of how to understand success, so that we know when it’s working? Isn’t administering clinical scales a good idea? It may feel burdensome to administer a suicide questionnaire, but who could argue that it’s a bad idea? I get it. It can be too much and feel overwhelming. It’s not a perfect set up. Still, painting these requirements as loathsome misses the potential significant benefits that these requirements may bring.
Again, I don’t mean to offend, but we can get lazy. When we unburden ourselves of these requirements, we can easily slip into avoiding them and the benefits they bring. In particular, when we flee from these requirements early in our careers, then we can develop bad, lazy habits.
I will sometimes hear complaints about the emphasis on billing, which I find curious. Most of us in the frum community are ardent capitalists, and quite a few charge large sums for their services in private practice. If an insurance company is paying for clinic services, why is it unreasonable that the payer wants some metric for or description of both the need for services and its progress? Or, from the agency’s perspective, what is wrong with trying to stay in business? Does the worker expect the agency to operate as a free charity? Does the worker intend to do so when s/he enters private practice? Again, it is all too easy to slip into a simplistic mindset that “they only care about billing,” but if people only cared about billing, they sure as heck wouldn’t be working for a non-profit. Again, they are most likely good people doing their best under imperfect circumstances.
Clinics operate in a societal context that provides them with significantly insufficient resources. There is not enough money for all kinds of things, including, and most importantly, for worker pay. This is a societal issue, not an agency or clinic issue. I have worked in many agencies. Each has its own strengths and weaknesses, but none are radically better or worse than others. It is entirely appropriate to inveigh against this societal state of affairs, but to lay the blame on clinics or agencies is misguided and childish. We all share a part of the responsibility as members of this society. There is nothing noble about retreating from the public health sector because it is imperfect.
I’ll resist the “kids today” lecture, but suffice it to say that we live in a society with less and less patience for frustration and imperfection. We cast things and people away when we don’t like them, and our tolerance for discomfort and boredom is exceedingly low. If I may be permitted a somewhat provocative statement, I would say the following: How can expect to help our clients cope with the imperfection and frustrations of their shules, spouses, jobs, children, and yeshivos if we can’t cope with the imperfections of the public sector of our own profession?
I will stop here. Every day, I go to work for a maddeningly frustrating big, slow, bureaucracy awash with difficult personalities, somewhat nonsensical policies, and a significant lack of resources. It is often frustrating. I might sometimes say the same for my own family. I’m not abandoning my family (though sometimes I want to), and I’m not abandoning public health or agencies. Every day we help a great many people in profound ways at a low cost. My agency, despite its imperfections, accomplishes amazing things, and I’m proud to be a part of that. I work with incredible people who teach me constantly, both those “below” me and “above.” It is my hope that this essay may inspire others, or at least give them the language to defend their valuable work.