What Really Matters
Looking back, that joyful collaboration on Pinocchio marked the end of an era. By now, managed care had carved its initials into the walls of community mental health. At first, I'd been enthusiastic about this new system of health delivery, as it promised greater efficiency of resources, more thoughtful case management and continuums of services, and an investment in preventive services. But managed care and other regulatory agencies, with their increasing demands for consistency, predictability, and accountability, began to transform the creative work of running a CMH center into drudgery. We were deluged with red tape—audit after audit, forms heaped upon forms. The behavioral paradigm—by its nature formulaic, easily reproduced, and predictable—came to dominate the community mental health ecosystem, like a species with no natural predators.
Working in a neighborhood clinic, I sometimes felt as if the walls were closing in on me. But I wasn't feeling just the squeeze of managed care; by now, the whole social infrastructure within which I worked was collapsing. Public schools were dangerous, prisons were overcrowded, the child welfare system was overwhelmed, and there wasn't nearly enough housing for people recovering from mental illness and addiction. It was all I could do to focus on one client, one family, at a time.
In 2001, I worked with Jamal, an 11-year-old boy who was acting up in school and not in the least interested in talking about it. I brought in his mother, father, and grandmother, who had differing expectations of the boy, but my attempts at structural family therapy went nowhere. Jamal continued to get into trouble with teachers and other kids, often landing in the principal's office. I worried that he was headed for suspension.
One afternoon, he came into session and just sat there, rolling a gum wrapper in his fingers. After a while he mumbled, "I wish I was in school." (Was therapy that bad, I wondered.) I asked why, and he replied that if he were in school, he could throw the gum wrapper at the back of someone's head.
"Why not throw it at me?" I asked.
"Because then I couldn't blame it on someone else," he said.
Jamal and I looked at each other. We both knew that something important had just happened: he'd caught a view of himself from the outside. It was the birth of an observing ego, a significant developmental moment that I hadn't anticipated or prepared for, or even especially contributed to, except to offer a space where reflection and insight might occur.