Category Archives: counseling

America’s Prison Problem

This article about a reporter who worked as a guard at a private prison in Louisiana is long, but it is a must read. Reading it so soon after that last season of Orange is the New Black, it was really grueling (there’s nothing about the show in the article). If you were wondering if for profit prisons are as bad as they are depicted in the show, the answer unfortunately is, they are worse. And the most enraging thing? For profit prisons are designed to keep people in the criminal justice system so they can continue to get paid for warehousing people.

We as a country need to ask if we want to continue spending millions to imprison people in depraved circumstances indefinitely, or if we want to set up a society that focuses on prevention and rehabilitation. There are many ways to do this. Improve our schools. Decriminalize drugs. Make sure every woman who wants birth control has affordable access to it. Increase funding for mental health services and respite care for people caring for family members with mental illness. Raise the minimum wage and tie it to inflation.

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Why I Didn’t Fight the School System

Since pulling my son who has mild autism out of the local ISD to homeschool him, I’ve noticed a divide in the responses I get. People who have worked with the schools or who have children who are differently abled are telling me that this is the best thing I can do for my son. People who have typically developing children and have not worked with children with special needs are baffled, though.

They wonder why I didn’t try to transfer Buddy to a different school, or why I didn’t address my concerns with the school. Or even try a different school district. And I can see why there is this disconnect. For the record, my husband never understood my insistence that I be able to pull our children out of school to homeschool should the need arise until he saw just how poorly Buddy was treated, how anxiety ridden Buddy became while going to the ISD, and how much calmer Buddy is now that he is out of it.

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Substance Use Treatment

I’ve been trying to write about the problems with substance use treatment in the US since I quit the field in November but haven’t been able to. I’ve been so burnt out from the topic that I even removed songs about drug and alcohol use from my MP3 list. Before I got a job at an outpatient substance use clinic about four years ago, I never had any interest in the subject. I was never interested in trying illegal drugs. I’ve never even smoked a cigarette. I have the occasional drink, but always stop at one drink per evening, and the only time I deliberately tried to get drunk was during my bachelorette party, and I really didn’t succeed because I didn’t like the feeling of being buzzed and stopped there.

The only history of substance use disorder in my family is my great-grandfather, who I never met.My parents don’t drink, not for moral reasons but because my dad, the pickiest eater of all time, just can’t stand the taste of alcohol. Aside from contending with asthma attacks triggered by second hand smoke, substance use did not affect me or my family growing up. Because of this, all of those contentious political questions about substance use that get everyone else so fired up didn’t interest me. As opinionated as I am, I didn’t have any opinions about legalization or 12 steps groups. I didn’t know enough or care enough to have an opinion about them.

Four years later, and I maintain that all of the issues are more complex than either side makes them out to be. But one thing I believe most people can agree on is the state of substance use treatment in the US is in shambles. NPR had an article about it today that just barely touched the tip of the iceberg.

So what do we need to do to improve substance use treatment in this country?

  1. Ditch the 12 Step Model and move to more evidence based techniques. OK, Alcoholics Anonymous and Narcotics Anonymous works very well for some people, but it does not work for the majority of people with substance use problems. Further, there are several aspects of these programs that conflict with modern findings about substance use and are dangerous for people in recovery. For a complete break down, see The Sober Truth.
  2. Primarily, the people providing treatment are LCDCs. LCDCs are poorly trained and tend to be in recovery themselves. I am an LPC and went to school for 6 years, have a Masters, and can treat the whole mental health spectrum. An LCDC goes to school for two years post high school at most (some with just a high school degree are grandfathered in, and the ones who tend to work in jails just have a certificate). They can only treat substance use, yet as substance use tends to be co-morbid with other disorders and, face it, substance use IS mental health, there’s a lot they can’t address. Further, counseling is more than just listening and giving advice (in fact, if your counselor is giving you advice I’d recommend finding a new counselor). And the sessions lead by and LCDC that I’ve set in on were not counseling. Some were cringe worthy. And further, a lot, but not all, LCDCs have serious mental problems themselves. There was one I was training when I was about to go on maternity leave in a week, and I had to tell my boss there was no way I could leave my clients with her. The least harmless thing she did was, when I gave her a list of referrals that I give to clients for case management purposes, she went to live at one of the women’s shelters listed. Knowing that we send clients there. Can you imagine going to live at a shelter and finding your counselor living there?
  3. As the NPR article addressed, the pay is poor. Especially for what the counselors have to deal with. People who go to substance use treatment are often forced into it. In our case, most of our clients have had their children removed by Child Protective Services. So we’re dealing with people feeling a lot of grief and shame because they lost their children AND who are in withdrawal. Some people come in very eager to cooperate and put their best face forward. Others, I can’t begin to describe the depths of their anger. Maintaining your cool and helping them to defuse that anger is draining. $40,000 a year does not begin cover the mental toil this takes on a person after awhile.
  4. The burn out. I was aware I was burnt out, but I wasn’t aware of just how bad it was until I got away from working there. And in my case I will say my boss did a lot to help us manage burn out. It’s why I lasted there as long as I did. We had work retreats about once a year. Last year, though, the Monday after my work retreat I spent an evening on the phone with a suicidal client who would not tell me her location (I did successfully talk her down). All of the relaxation I got from the retreat was undone by that Monday and I was even worse than before I went on the retreat. Suicide calls are emotionally draining and extremely anxiety provoking for counselors because we’re put into a confidentiality trap (if we break confidentiality and call the police, we could be sued successfully and lose our license, but if we don’t call the police and they kill themselves, then we can also be sued successfully and lose our license). Add to it that I, like most counselors I know, struggle with anxiety, it put me in a real bad spot. Really I think there needs to be a counselor contracted with clinics that counselors who work there can go to free of charge. The other thing my boss wanted to do but she could never get the staff to do it was have a counselor rotate among the staff so the counselors could have a break to develop curricula or do research or something else, but have a break from working with clients while still doing work vital to the company. I think having these role changes would have helped. And here’s the thing, having counselors who are energized and clear headed helps the clients. So it is vital the make sure the counselors are kept emotionally healthy.
  5. Increase the length of stay for people in treatment. It takes time for the brain to heal from substance use. Outpatient programs are about three months long. When a person stops using drugs, one of the times they are most likely to relapse is three months after getting clean. See a problem? Further, a lot of the times the problems a person coming in for treatment faces are so complex it’s going to take a lot more than three months to fix.
  6. Get as much of the family in treatment as possible. When one member of the family has a problem, the whole family has that problem. A lot of times I would feel like I put a fish in the bag, taught it some nice coping skills, and then threw it back in with the sharks. People with substance use disorders tend to come from families who have problems with substance use. Very few of them are willing to say good bye to their family forever or to tell them they can’t use drugs around them. So that individual completes treatment, and most of the time I think they genuinely believe they will be strong enough not to use around their family, and then BOOM, they’re back in treatment.
  7. Evidence based treatment, evidence based treatment, evidence based treatment. This means cognitive behavioral therapy. This means accepting that medication may be useful for some people rather than treating that medication as another addiction. However, it also means not going the opposite extreme and expecting to give a pill as a solution to every problem (as I said above, the reality is more complex than any side would maintain). Here’s what we do know, though. Addiction is not about will power. There is a biological competent. There are maladaptive thought patterns. A person’s environment plays a strong role in whether or not they will relapse. Good treatment needs to take all of those factors into consideration.

OK, that’s all I can do about this topic today. May be in another three months I’ll write more.

Parenting without Rewards and Punishments

Before I had Buddy I was a firm behaviorist. My dad liked the works of B.F.Skinner, and while in college I did therapy with children with autism based on behaviorist principals. In a nutshell, desired behavior was rewarded, undesired behavior was ignored. This worked well for me in college. And it worked well for me in a children’s hospital.

I even used these principals to train my dog, a German Shepherd named Amelia who had spent years in a shelter and was not well socialized when I adopted her. One of the things she used to do was bark if more than two people were in the room or if we were watching tv, making conversation or listening to the tv impossible. We broke the habit by immediately leaving the room if she did it and giving her attention if she was in the room with us and quiet.

Buddy came into the scene, and with him I’ve had to throw behaviorism out of the window and embrace more cognitive theories. I also had a challenge. Buddy may have autism, but he is also incredibly smart. He doesn’t like being manipulating into doing things for rewards, and punishments don’t deter him, if anything he retaliates. This didn’t just have implications for his behavior, but for things like speaking. Speech therapy has been challenging for us, largely because he’s aware he’s being manipulated into speaking and would refuse to speak just because he was being manipulated.

For instance, one time I found I could get him to say “again” if he wanted me to read a book again if I sang “again.” He’d sing it with me. This worked for two nights. Then if I sang “again” expecting him to join in he’d just get off my lap and move on to a different book. This flies in the face of behaviorism.

Rewards do not motivate, punishment does not deter. Considering my behaviorist approach to my clients and dog, this was quite the curveball. He has a high need for control of his environment and getting into power struggles with him is something I constantly have to be on guard for (on the plus side, I do not worry at all about peer pressure when he’s a teenager. If he doesn’t want to do something, he will not do it!) And what works very well one time might not a second time if he feels he was manipulated, so I’m constantly being creative with him.

Even with these challenges, I’m making progress raising him with respect and helping him to learn how to control his emotions and reflect on his behavior and figure out the best decision on his own. Here’s what it boils down to.

  1. Environmental modification. All parents do this to some extent. Baby proofing. Buddy is sensory seeking and craves stimulation. One way he does this is by dumping all of his toys on the floor and rolling on them. And then there was the time he was fascinated with the flour. He would keep going into the pantry and dump it on the floor and play in it. He’s also a climber. We got a lock for the pantry to keep him out. The other problem we had was him trashing his room. I’d bought a lovely organizer for all his toys, and he kept dumping everything on the floor and rolling on it. Eventually I moved his toys to a separate locked room and I only get out certain boxes each day.
  2. Routines. Like a lot of kids with autism, Buddy thrives on routines. Things like wearing a seat belt or helmet aren’t an issue with him because he knows it’s the routine.
  3. Lots of outdoor time. Exposure to natural light. Running, hiking. All of the textures he’s exposed to. When we can’t get outdoors much because of the weather or being too busy I notice he acts out more. And time outdoors helps with the impulsivity.
  4. Teaching him to manage overwhelming emotions. This has been difficult because he does not imitate and does not like being manipulated. When people get mad, we often forget to exhale fully, which causes carbon dioxide to build up in our system and increases the feelings of anger. This is why breathing techniques are taught as part of anger management. One time when Buddy was melting down I saw some bubbles on the window sill and grabbed them, held out the wand and asked if he wanted to blow bubbles. He started blowing bubbles. AND he calmed down. Finally I’d found a way to get him to do breathing technique when he was angry! When he’s angry or hyper I would run for the bubbles. Now I’m at the point where I can prompt him to blow bubbles and he will exhale even if he doesn’t have a wand.
  5. Asking reflective questions. He’s less likely to respond if I give orders. For instance, while taking a walk when we get to the street if I ask, “What do we do when we get the the street?” He’s more likely to stop, and as he’s lately started saying, “wait,” if I say, “stop when we get to the street.” he’s more likely to run into the street. Most of the time he knows what he’s supposed to do, he just doesn’t want to be told what to do. The other day he took Sissy’s special toy monkey, which resulted in lots of tears from Sissy. I asked, “What that a nice or not nice thing you did?” He thought about it. Then I asked, “What would be a nice thing to do?” Amazingly, he handed it back to her.
  6. Always have an activity on standby for him to do. Having too much unstructured time leads to him destroying the house or acting out. If he starts getting antsy I grab an art project or sensory activity. It doesn’t have to be fancy or expensive. I currently have him drawing pictures in colored salt (just add food coloring) on a cookie sheet. And as he is sensory seeking, he loves this stuff. Another standby is cornstarch and water. It makes this gooey substance that he loves playing with.

I still can’t have conversations with Buddy, but he’s shown that if I asked him to think about his behavior he does. And ultimately that’s what I want. I’ve noticed that some people approach parenting believing they can control their kids and have to force morality on them, while others respect that kids are going to make their own choices and our job is to teach kids how to make good choices. I obviously belong to the latter group. I’m not always going to be there to police Buddy’s behavior, so he is going to need to know how to behave appropriately when I’m not around.

Cleansing Time

Three weeks ago I left my job. The month started off rocky as I had my first UTI and then my kids got a stomach bug. But things have since settled down. We’ve gotten into a good routine, but more importantly I’m starting to recover emotionally from burn out.

I’d worried that I would go insane at home with the kids, but I’m actually enjoying it. I had been working four tens, getting up at five and waking my husband (and he is not someone who is easy to wake up and get moving, truthfully, it is easier to get my autistic five year old up and moving than it is my 34 year old husband) and kids up,. And since Andy does not do mornings, I was the one getting the kids ready and in the car and dropped off at daycare. And I am not a morning person myself. The pressure of doing all of this was getting so bad that I would wake up at 2AM and stare at the ceiling for three hours, unable to sleep due to the worries about oversleeping and failing to get everyone out of bed and out the door on time.

Now I sleep through the night AND I get to sleep in till 7, have a leisurely breakfast with my kiddos and then take them for a walk.

Buddy got a bike for his birthday, and he loves riding it. Every morning he talks excitedly about riding his bike, and I love watching him ride it. He’s very good at stopping when he gets a certain distance away from me and Sissy and waiting for us to catch up. Sissy insists on walking the 10 minute walk to and from the park like a big girl, though I carry her on my shoulders if need be. She’s becoming quite the naturalist and loves chasing birds and looking at plants and trees and collecting what she finds. And considering I don’t have a lot of mental energy in the mornings and tend to become more productive as the day passes, I like being able to take an hour or two (yes, we stay there that long, and usually I’m dragging the kids home because they don’t want to leave) in the mornings to just enjoy being outdoors without doing anything emotionally taxing.

One thing I worried about when I started to accept that Buddy had autism was his ability to bond with his sister. And I can happily say they are bonding. They both love being outdoors, eating popcorn, reading, dancing, listening to music and they’ve even started singing together. And at night during their bedtime routine they’ve started cuddling with each other when I sing. Yes, they also tease and torment each other and if one of them dares touch the other’s toy it’s WWIII, but that’s part of having a sibling. Overall they seem to like each other, which is good, because they’re stuck with each other!

Monday, after a fun two hour visit to the park in which Buddy and Sissy threw a tons of rocks into the creek, I got an email from my business partner talking shop, and I remembered that heck, I’ve got to get back to work in January! It was a bit of a shock just how much I was enjoying my breather, but it’s more than that, it’s been healing.

One thing I’ve found is that most counselors experience a lot of anxiety. I’m no exception. Strangely our clients tend to think we’re perfect beings who don’t understand the anguish of anxiety, but trust me, odds are if you’ve ever seen a counselor, that counselor has struggled with anxiety.

I was starting to reach record levels this year. For the last four years I’ve been working with clients who are essentially compelled to go into treatment to get their children back from the state or for probation/parole. Naturally, these people are not exactly excited about treatment, and have serious mental health issues that warrant state involvement and tend to be a difficult bunch.

When I was fresh and excited about my work, one thing I loved was seeing a pissed off, difficult client start group and transform into someone motivated and pleasant. In fact, some of my favorite clients started off as my more difficult ones. The group process is amazing, and by and large once people realized I wasn’t going to preach morality at them for 3 hours a day they tended to come around and were eager to work on their issues.

However, while a lot of the times there were good outcomes, sometimes there weren’t, and strangely, dealing with someone who was a reluctant newby didn’t become easier with time, it became harder and more and more emotionally taxing. There was a sense of, “well, I got X number of people motivated, and still more come in.” I just didn’t have it in me to continue dealing with the anger and resentment people have when they start treatment. And knowing that someone is only coming to see you because they fear the consequences of not doing so isn’t exactly good for the self-esteem.

Worse, seeing the new people was causing clinical levels of anxiety for me. When I would see a difficult or reluctant client it would get so bad that my chest would feel tight and I would have difficultly breathing enough to speak. It was hard for me to not think about all the bad ways a session could go or wonder if I would finally have someone go off the rails and do something horrible. I even had one that I worried was going to come into the office with an AK-47 and start shooting.

Combine this with caregiver fatigue. At work I took care of people. People who by and large have experience trauma. And then at home I took care of people.

To handle it I started detaching emotionally at work. I was pretty much doing what doctors do. I went to work for 10 hours and didn’t feel and walked around detached. It didn’t matter what anyone said or did to me because I’d turned myself off. It’s not a good way to live or practice counseling.

I have a lot of thoughts about CPS, probation, substance use and treatment, but I still can’t get those down yet. I’ve tried several times to get something together but keep hitting a dead end.

Overall I really needed this change. At the time I realized I was detached but I didn’t see how bad it was. Now I’m moving onto a career where I will be seeing clients who aren’t being forced to attend treatment, and my friends who have gone down that path before me assure me it is easier on the ego, more satisfying and less soul crushing. In some ways I’m kicking myself for not getting out sooner, but I think the important thing is that I got to this point.

Because it means beautiful mornings walking in the park with two little people who want to be with me more than anyone else in this world, as opposed to a cheerless room with a group of people who are compelled by the state to be with me. I’ll take the former, any day.

Disappointed in Humanity

Last Friday, my usually even tempered Sissy became irritable. She’d dissolve into tears at the slightest thing. She started running a fever and lost her appetite. Then she got a rash on her hands and feet. In short, she got hand, foot and mouth.

I’d never heard of hand, foot and mouth until Buddy caught it a few years ago. Buddy’s case was very mild. A mild rash, I don’t think he even ran a fever and it didn’t seem to bother him any. Sissy’s case was a lot worse. She was in so much pain she couldn’t sleep for more than thirty minutes at a stretch and woke Buddy up with her screaming. Andy and I took caring for them in 4 hour shifts through the weekend. By Sunday we got her sleeping mostly through the night again, though Buddy’s sleep schedule was so thrown it’s taken him till yesterday to sleep through the night (autism and sleep problems go hand in hand). Her fever broke over the weekend, but the rash has been persistent. Andy stayed home with her Monday, while I stayed with her Tuesday and Weds, and Andy again on Thursday. I think/hope the rash will be completely gone tomorrow.

Friday, of course, was when the attacks on Paris happened, and it was while comforting a distraught Sissy that I read about it. So many thoughts, so much to say, but mostly in addition to being physically weighed down, I was emotionally weighed down as I thought about the consequences of the attacks.

On Monday I went to work. Whether or not to tell my boss I was planning on leaving was something I grappled with, and eventually I had to come out and do it simply because to get on insurance panels I would going to need access to a database that they had my information on, and there was no way to get access without them knowing. I was scared to let them know, given my history of working for companies that react poorly when people give notice that they are leaving.

The good news was that I had originally told them I’d leave in February. I assumed that getting on insurance panels would be a tedious, drawn out process. Thankfully it hasn’t been, and I’ve got that part done. Now I just need to build a client base. The bad news is no one wants to start counseling around the holidays. So I told my boss I’d stay through December. I wasn’t exactly thrilled. I’m burnt out and ready to leave, and I was worried about emotionally balancing full time work, private practice AND family responsibilities, but I also wanted stable income during the holidays.

Well, on Monday they told me that starting in December I would have to work part time. Considering the cost of daycare, can’t. What I would bring home would barely cover the cost of it. So I turned in my two week notice.

In some ways I’m relieved that I won’t have to stay through December and, if I do manage to get some clients, I won’t have to balance seeing them with a full time job and taking care of my kids. In some ways I’m mad that my hand was forced. Predominately, I’m numb. I’m exhausted, both physically and emotionally and I’m just ready to be done with this job and to move forward.

Cut to today. It’s Buddy’s fifth birthday! I picked him up from daycare and took him to the store and told him we were getting a birthday cake. He got excited. “Cake! Birthday! Give you hug! Give you hug!” he exclaimed as he ran and hugged me. For him, this is very impressive communication and encouraging.

He happily chose some cupcakes from the bakery. When we got home, we found that Andy had gotten hand, foot and mouth from Sissy. Adults usually don’t get it, so I wasn’t worried about her giving it to us, but it looks like I should have been. For the record, Andy says it is very painful. And Andy can be a rather big baby about these things. Really, I’d rather be sick than him be sick!

So I loaded the kids in the wagon to take them for a quick trip to the playground before it got too dark. While there I got a phone call. Hoping it was from a prospective client I picked it up.

“Who is this?” a female voice of indeterminate age asks.

Stupidly I told them my name. I was still thinking/hoping it was a client. “Who is this?”

“Riaza.”

“What are you wanting?”

Silence. A giggle. Then a little boy says, “We’re going to blow up your daughter.”

“What?” I said, stunned.

More giggling, “We’re going to blow up your daughter.”

I couldn’t believe what I was hearing on the phone. They hung up. I stared at my kids on the playground in shock. The phone rang again, it was from the same number. I picked it up. Silence. Then I said, “I have caller ID and if you keep harassing me I will call the police.”

They hung up and did not call again. And yes, they were stupid enough to not block their number.

By then it was dark. I was a little bit unnerved. I gathered up my kids and went home. While I got Sissy ready for bed my husband and mom started a reverse number search on the number. It wasn’t anyone we knew, and the LinkedIn profile of the owner shows someone in a prestigious position at a big bank. We’re thinking his kids got a hold of his phone and played a really sick prank. My mom has messaged him on LinkedIn.

It’s sick enough making threats against someone’s daughter, even if you have no intention of acting out on them. But using an Islamic sounding name and making threats to blow her up takes it to an even worse level. Because it perpetuates ugly stereotypes against a group of people and fuels terrorism. I just cannot put into words how disgusted I am by their actions.

Sissy got off to bed. We gave Buddy his gifts and they were all hits. And then he went to bed. It’s been an exhausting week for him as well. And now I’m trying to process everything that has happened and remember that there have been encouraging things even though this week has been draining. I didn’t feel like I had a weekend last weekend because taking care of Sissy was so grueling so I went into this week drained and exhausted and running on fumes, and found I was in for a pummeling when I didn’t have a lot of emotional energy to spare. Now I’m even more drained, exhausted and, though I’m trying to cling to the speckles of hope I’ve found here and there, just disappointment in humanity.

That’s it. That’s how best to describe it. This week, I am disappointed in humanity. We can do so much better.

Social Inequities

This article about fairness struck a nerve with me. I’m a counselor, and my clientele consists mostly of people who live in extreme poverty. Working with this population is frustrating for many reasons, but by far the biggest challenge is that the system is so stacked against them. As a counselor, I work with the individual, and I have to believe in an individual’s ability to change his or her life. But when I see people constantly being pushed back by a system that does a better job of keeping them in severe poverty than lifting them out of this, this gets challenging.

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