Thursday, January 26, 2012

I know everything I need to succeed in life...

Occasionally, I run across family systems that are heartbreaking.  Consider the following: my client: a middle-school aged kid.  His mom requested I work with him because of his behavior at home and at school.  Seems that all he wanted to do was play his Xbox.  He is very smart and schoolwork holds no interest for him, so he sometimes refuses to go to school.  His mom says that he often throws tantrums when he doesn't get his way.  He is close to neither parent and his siblings are old enough that he may as well be an only child. 
Using open ended questions, I discovered that he considers himself to be decently happy and content with himself, but has few friends.  Asking about the presenting issue as described by his mom, he admitted that he is spoiled.  I asked him to finish the following statement, "The most important thing in life is..."  his answer: to not be bored.  Though he is not a child of the 1990's, my brain sparked and connected to the grunge band, Nirvana and their hit, "Smells Like Teen Spirit."  Part of the chorus pleads, "here we are now, entertain us!", helping the song to be hailed as the anthem of an apathetic generation who only wanted to be entertained.  As I continued to dialog with the kid, I learned that he described his relationship with both his mother and father as distant and faint.  Developmentally, it is my understanding that most children find their identity and sense of self through their connection with their family.  At his age, he should be starting to develop his identity apart from his family, but it seems like his family identity was never really formed, as he feels no attachment or connection, only entitlement.  Trying again to get a sense of his value system, I asked him to evaluate the following quote: "Show me the person you emulate and I shall know by this measure, better than any other, who you are yourself."  The young man was quick to analyze the sentence and reflected to me that he understood its meaning.  But when I followed up with, "So, who do you admire?  Who in your life is someone that you can see yourself growing up to be?"  He thought for a few minutes and then shrugged and said, "No one, really.  I think I know everything I need to succeed in life."
At first, I had to stifle an urge to laugh at the seemingly preposterous statement I'd heard.  My bemusement quickly turned to pity when I realized that far from being cocky or feeling entitled, this young man's problem was not a character flaw in himself, but a failure in his family system.  I felt sad for him because his parents don't know enough to challenge him or help him have a healthy sense of self. 
I have come to understand, as I work with various families, that kids' behaviors and beliefs are generally a response to their environment.  So, as I am presented with a kid whose troubled behavior or attitude is labeled by their parent as the presenting issue, I am always careful to examine the family system and try to work with the parent to depathologize the kid and help the parent to accept some responsibility for the resulting behavior which they say they don't want.
Anyhow, I am saddened because my role in working with this boy is limited and in order to really address the core issues, the needed work is with the family system, something that is unlikely to happen.  I think the best I can hope for in this situation is relationship triage, not relationship repair (as it relates to helping this young man to have a healthy connection to his family).

The situation invites me to reflect on my own family functioning.  How would my children be affected if I viewed their behavior as a function of their response to the environment that I create for them in our home?  Now, I don't want to take absolute responsibility for their actions, but do I really recognize and honor the influence I have on my children, or do I discount it?  If I have generally happy children, how am I influencing their happiness?  If I have generally anxious children, how is our home environment encouraging them to be anxious?  If my children are generally angry and hateful, what kind of environment am I providing for them?

Nietzsche wrote, "When you look into the Abyss, the Abyss looks into you," reminding me that I do not remain unaffected by the families that I encounter in treatment.  Even as I hope to influence them, I recognize that I am influenced in return.  Hopefully, I will embrace the opposite philosophy that my young friend espoused and will find freedom to grow by knowing that far from having everything I need to succeed in life, I recognize that I know nothing.  And that is the beginning of wisdom.


Monday, January 16, 2012

Obstacles, Barriers and Hoops to Jump Through: Bureaucracy at work

I started on my journey to become a therapist several years ago, when I decided to go back to school and get my Master's in Marriage and Family Therapy.  Just getting a degree isn't the end of the process, though.  Once one has one's diploma in hand, one must obtain a license from the state to practice as a therapist.  Licensing and regulation are as old as government and serve to protect the public from any old person labeling themselves a therapist and setting up shop.  However, whenever you have government regulating things, you will inevitably experience red tape and bureaucracy.  Here is a narrative of my troubles so far: Jeff's Licensing Journey.

So, I requested to have my situation brought before the Licensing Standards Committee of the Texas State Board of Examiners of Marriage and Family Therapy and was added to the agenda for the meeting on Friday, January 13th, 2012.  The outcome of the meeting was that the Committee is requiring me to accrue an additional 700 hours of client contact before I can be awarded my license.  That is the short story.  If  you want to know details and my opinion of the situation, read on.

Here are the facts to keep in mind:
1) The critical step that I missed was that the Board requires a Supervisory Agreement Form (Form III) to be on file and approved by the board for each location that a LMFT-A will be providing services.  I had one on file for my hours at TFI, but not for New Horizons.
2) Over the past year or so, the Licensing Standards Committee has had so many LMFT-As  appear before them for a waiver of that rule, they have changed the wording of the rule to be more clear and added a block of text on the FORM III at the top of the form, in all caps and in bold, so it can't be missed. See a copy of the revised form HERE.  Here is the previous form, for comparison: HERE.

The problem is that the rule that was violated was unclear in the first place, as evidenced by the fact that so many people have missed it and by the fact that the board apparently felt the need to change it for clarity.  Here is the wording of the rule as it appears in the Texas Code:
Texas Administrative Code, Title 22, Part 35, Chapter 801, Subchapter G, Rule 801.142(D) “Supervision must be conducted under a supervision contract, which must be submitted to the board on the official form within 60 days of the initiation of supervision. The supervision contract submitted to the board must be approved by the board. Fees charged by a supervisor during the course of supervision, which occurred without a board-approved supervision contract in place and subsequently resulted in the supervised experience hours of the supervisee being denied by the board solely on the basis that there was no board approved supervision contract in place within 60 days of the initiation of supervision, must be reimbursed to the supervisee.” 

 So, according to this rule, I had to have a supervision contract in place within 60 days of the initiation of supervision.  Check!  I did that.  I submitted the official form (Form III) and happily started seeing clients on a part-time basis at Texas Family Institute.  The form (Form III), has a spot for the licensee information (that is me) and where services will be provided (TFI).  Then it has a spot for the supervisor's information and the supervision schedule.  Then, it has spots for a notary to sign off and volia!  You are done!  Now, I will grant that the inclusion of a line on the form asking where services will be provided does indicate that the information is important to the board.  However, there is nothing explicit on the form that indicates that if you provide services at a second location, it would necessitate filling out a new form.  On the other hand, if you have a second supervisor, it makes logical sense that you would need an additional supervisory form on file.  In fact, there are other rules that state a supervisee can only have two supervisors at any given time in the process.  So, not only is it a logical thought process, but there are multiple rules that discuss how to handle having multiple supervisors, but none that specify what to do if you have more than one location that is being supervised by only one supervisor, as was my case.
A month after I started working at TFI, I was hired by another non-profit organization where my job would allow me to accrue hours toward my license, but they had no LMFT supervisor available, so I asked my original supervisor if he would supervise those hours as well.  He agreed to do so and my new job allowed me to take time each week to attend supervision sessions with him.

So, did I fail to turn in a form that was required by the board?  Yes.  Was I at fault for my negligence?  Well, kind of... you see if I was the only one who misunderstood, then it would stand to reason that it was my own lack of diligence or intelligence that was at fault.  However, by the board's own admission, this rule is unclear and confusing to people in my situation.  So they changed the rule.  They changed the form.  And it is at this point that I feel that the Supervisory Committee handled my appeal poorly.

When time came to address my appeal, the Executive Director informed the board of my situation, gave them time to look over my narrative (linked above) and some support letters from colleagues who knew my situation.  The members of the committee asked a few questions for clarification.  There was some discussion between the committee members wherein they acknowledged that my case was not the first time they had heard about this situation.  They mentioned that each time, the details were examined and that the board had made some inconsistent rulings about other's cases and they joked about needing to be consistent in their inconsistency.  Then the chair called for someone to motion that they look at the how many hours I still had remaining that weren't approved and that they split the difference with me, accepting half of them and requiring me to make up half of them.  I interrupted and asked if I might speak and give further details.  The chairperson sat back in her chair and said, "Okay... dig yourself a grave."  That comment was offensive to me, as it indicated to me that her mind was already made up and that whatever I was about to say would only serve to damage my appeal.  I spoke for a few moments about my perspective on the situation and acknowledged that the decision was in their hands, but also the power to grant my hours, all of them.  I noted my service to the community, the fact that the rule was unclear, that my supervisor knew he was supervising the hours and that I had complied with everything else that was required of me, including renewing my LMFT-A for the three months between my denial of hours and the chance to appeal.  After I spoke, the chairperson picked up where she left off, as if nothing in my statement held merit and again requested a motion for splitting the difference of my remaining hours.  The chairperson looked at me and said that the board was willing to admit that the wording of the rule was unclear, but that I had to admit that I'd done something wrong by not filing the paperwork.  So essentially, the committee was asking me to admit that I had deliberately not filed a paper that I didn't know I was supposed to file because by their own admission, it was unclear and confusing.  This seemed to make sense to her and when I protested that it was unclear, she told me that it was my responsibility to make sure I knew everything I needed to know to file things correctly.  She said it was the Board's responsibility to protect the public from incompetent therapists.  Again, I was offended by her suggestion that because I didn't file a form that was required because I didn't know I needed to because the rule was unclear and confusing in the first place... that somehow made me an incompetent therapist.  I was nonplussed and didn't reply.  The chairperson pressed forward and put pencil to paper with the numbers for the hours I had documented previously and had been accepted and calculated how many remained and told me that I would need to complete 700 hours more of face to face hours and then re-submit my application for upgrade.  Another committee member made a motion to that effect, it was voted on and I was done.

As I drove home, during my 4 hours on the road, I was able to mull over what had happened.  I feel that although I did have a chance to appeal the staff decision, that my appeal was not really considered.  I feel that due to all the previous cases they'd seen, the mindset of the committee was that I needed to be held responsible for the crime of not filing a form and that I somehow should have known I needed to file it despite it being unclear and confusing, given my circumstance.  I further feel that the mindset of the committee was driven by the chair, as the only other committee member to ask any questions about my situation was the public member, a MBA, who had never been through the licensure process himself.  The rest of the committee seemed to follow the chairperson's lead.

With just a little effort, I can think of several outcomes that would have been much better for the committee and for myself and my community.
1) Acknowledge that there is a situation where the wording is unclear and in those cases, simply require the licensee to fill out the form, have their supervisor sign it and have it notarized and applied retroactively.  After all, if the purpose of a board-approved supervisor is to monitor the supervisee in the first place and ultimately, it is the supervisor who signs off on everything anyhow, why make this more complicated than it has to be?
2) If the board felt that there needed to be some accountability on my part for not filing the form, they could have required me to continue in supervision for a set period, a fine, the denial of some of my hours ( a reasonable amount, not all of them)  In fact, because I'd renewed my LMFT-A while waiting for my appeal, they could have accepted the 200+ hours I'd accumulated in the meantime and counted that as recompense for not filing the 2nd Form III.
3) As the committee repeated bemoaned the fact that there were so many licensees who were coming before them with this problem, they could have granted my appeal and then enlisted my help in informing others who had not yet completed their hours to contact the board and rectify the potential problem before it had to turn into an appeal.  After all, I am in contact with my cohort and other licensees who are in a similar position.  I have anecdotal evidence of several others who have experienced a denial of hours, to different degrees, because of the same set of circumstances.

At any rate, I feel that the mindset of the committee led to this appeal being handled unprofessionally, and, according to their own comments and my anecdotal evidence, it was handled inconsistently.  The end result is not just a faceless licensee having to do a few more hours toward a license.  The end result of this appeal has numerous consequences for me, my family, my community and the practice of MFT in the state of Texas.  Consider these consequences:
1) My career is delayed for 5-7 months (or more) while I continue to strive toward these hours.  I am having to work several jobs at pay scales below my education level as a result of only being provisionally licensed.  I can't get on insurance panels with a LMFT-A.  I have to be fully licensed.  So, in the mean time, I can only accept private-pay clients.  Current economic conditions notwithstanding, most folk can't afford $80/session and so I am forced to accept low-paying clients.  I don't mind helping with that, but it is hard to feed my family and pay off my school loans when I can't charge a reasonable rate for my services.
2) Clients who have state insurance can't utilize my services because I can't accept their insurance.
3) The non-profits, and coalitions that I serve who may have benefited from my credentials are also forced to wait until the hours are completed.
4) As other students and provisionally licensed people hear about how the board handles situations like this, it can influence them to seek other avenues of licensure.  I know of several in my cohort from school who opted to get LPCs instead of LMFTs because of difficulties in obtaining a MFT license.  How can our profession continue to advance itself in the state if those who are trained in Systems Thinking and MFT modalities opt to practice under LPCs and LCDCs and Social Work instead of working toward MFT credentialing?

So, while I am primarily disappointed because of the effect on me, my family and my practice, I recognize that the implications go beyond me.  700 hours represents approximately 5-7 months for me and in the mean time, opportunities that require a full license, which I have already earned, pass me by.  I have already spent three months waiting, so in effect, a year of my life, livelihood and career are gone due to a confusing, unclear rule and the hard-heartedness of a panel of MFTs.


Wednesday, January 11, 2012


My favorite Christmas gift this year was not found at Best Buy.  Several days before Christmas, I was told that my presence at Nana's house would not be appreciated.  Apparently the kids were hard at work painting and preparing the letters for a present they wanted me to have.  It was a simple block of wood, painted matte black with letters that spelled out a simple message: "I love you... more".  Like most precious gifts, the value to me is not in the price of the wood, or the effort that went into mounting the letters.  Rather, the gift is in the symbolism. 

"More" is the name of a song by Matthew West.  It is part of a ritual I have with my kids.  We often exchange the endearment, "Love you!" when taking leave of each other and it grew into a kind of send off every morning when I drop them off at school:
Me: Bye, kids.  Learn a lot today!  I love you!
Ethan: I love you, too!
MH: I love you, more!
Ele: ... than the sun...
Me: ... and the stars...
MH: ... That I taught how to shine...
Ethan: ... you are mine, and you SHINE for me, too!

and on and on till we've sung out the chorus to each other.  So, this present they made for me is more than just a cute remembrance.  It is evidence to me that I have succeeded in impacting my children with a ritual.  This will be a "my dad used to say this to me all the time" kind of thing for the rest of their lives.  When they hear the song on the radio, they'll think of this connection and know they are loved.

Rituals are important for families.  For some, sitting down to a family meal is a ritual that binds them together.  Vacations, road trips, traditions, they can all be sorts of rituals.  I think of the sacred rituals that connect us at church: the singing, the prayers, the sharing of the Lord's supper.  Our congregation has a ritual where we close each worship service by singing, "Doxology".

Parents, if you don't have some sort of "I love you" ritual with your children, I urge you to develop one.  They help to deepen our children's sense of attachment and belonging to family and are part of a healthy way to build emotional safety in the family.  A child's sense of self-worth and identity are formed, in large part, by the relationships from their family of origin.  I can't think of a better gift that we can bestow upon our children than a deep and long lasting sense of being loved and cared for.  Maybe, it'll mean so much to them, they'll make a plaque to commemorate it. >grin<

-I love you, dear reader... more.