Clinical Intersections: Can I Be Real a Second?

by Dr. Danna Bodenheimer, LCSW

     Somewhere in the middle of Hamilton, the play I mean, George Washington turns to his general Alexander Hamilton and says:

Check it—

Can I be real a second?

For just a millisecond?

Let down my guard and tell the people how I feel a second?

     It’s such a simple line, but one of my favorite in the whole play, which I have memorized to a fault. It’s a moment of vulnerability and honesty, when a leader turns to a colleague and just tells the truth about how he really feels, the terror deep inside of him. He starts to explain how truly unprepared he feels to fight the American Revolution, short of supplies, soldiers, and solid morale. I love this line, because I get it and I feel it. And I want to ask the same of you, my fellow social workers: Can I be real a second, for just a millisecond?

     Things aren’t feeling great. I don’t mean just inside of me; I mean everywhere. I know you know it, too. It would be impossible not to. This is what it looks like from my corner of the social work world, and granted it’s just one corner. When I supervise a school social worker, she is torn between telling the administration the truth about just how badly a kid is fairing emotionally and risking expulsion or holding it inside because she knows that the only stability in that kids’ life is school. When I supervise a hospital social worker, they know that they are creating a fictional discharge plan to make the hospital feel okay about needing the bed back because insurance has said that they are no longer going to pay for the stay. When I supervise a social worker who is on the front lines of the opioid epidemic, she tells me that Medicaid won’t cover a psychiatric stay for someone with psychosis because of the drug history and resulting liability associated with it. And when I sit with a social worker in a domestic violence shelter who has a trans victim, there are no shelters available that will offer them a safe space to stay because their biological sex and gender identity don’t clearly match.

     And those are my supervisees.

     As for my own clients, well that’s a whole other story. I have a client who is so anxious that she wants to jump out of her own skin. She is not being adequately held by weekly therapy sessions. Twice a week isn’t exactly helping, either. She is turning toward Ativan or Xanax and the ER. The ER won’t admit her, because she isn’t suicidal. Another is pregnant and working on her medical residency. Her husband is a teacher. They won’t be able to afford child care for the their second kid who is coming in August. A teacher and a doctor cannot afford child care for two kids. It’s that simple. Yet another is trying to make ends meet on his own social worker salary amidst an endless sea of calls from student loan companies warning of the dire consequences of missed payments to his financial future.

     And those are my clients.

     And then there is you, the social workers reading this post, published during Social Work Month, the month when we are to be celebrated. And I want to celebrate you, and the way that I want to do that is by telling the truth. I want to tell the truth about how hard you are all working, how little you are getting paid, and that what you are doing is the single most important work being done in the world right now. I mean that. Because the words social and work, alone, mean that you are in the trenches of working with relationships, securing attachments, studying development, mitigating the impact of trauma, creating treatment plans, setting goals, and managing symptoms. You are in the business of simultaneously seeing truth and holding hope. And you are ALL doing it in under-resourced environments, making less than you should. Despite that, though, you are persisting with creativity and gusto and the most important and transformative skill of all, you are doing it with love, even when you are tired.

     Washington turns to Hamilton:

I cannot be everywhere at once people,

I’m in dire need of assistance…

I’m being honest

I’m working with a third of what our Congress has promised

We are a powder keg about to explode

I need someone like you to light the load.

     It’s ironic or funny or scary (I’m not sure which, really) that these lines were being uttered (though fictionally) at the front lines of the American Revolution. I wonder if that is not where we all are, too: on the front lines of a Revolution.

     Let’s say that we are. I think that we are. And I think this means a few things.

     First, I want us to all be careful about the obsessive talk about self-care. Self-care is a wonderful thing, for sure. But it isn’t simple and has become a part of a large “wellness” industrial complex that is putting the pressure back on you to refuel yourselves in ways that are often financially out of reach, take up time you don’t have, and offer short-lived fixes. Interestingly, it was right before the height of World War II that Germany became obsessed with Pilates. It is possible that in times of dire social strife and stress,  we are encouraged to turn the labor of staying sane back onto ourselves. And perhaps this is part of a long trend of depleted folks being told to fill their empty tanks somehow, just somehow.

     Second, revolutions (at least healthy ones) are fueled by obsessive truth telling. The more truth that is told, the less that gaslighting can prevail as a tool by which we remain oppressed. If you see a discharge made to a homeless shelter that you know has no beds, you have to say it. If you see a restraining order being denied and you know that it is going to end in a homicide, somehow, you have to say it. If you see a colleague transgressing professional boundaries, you have to say it. And if no one is going to listen, then write it down and send it around and make it public and take the risk to shine the light on what is really going on. Being the canary in the coal mine, be the loudest canary you can possibly be.

     Third, ask for more money. Ask for it early; ask for it often. Ask for it every time you gain another year of experience; ask for it as your level of licensure increases. Ask for it every time your caseload grows by five or by ten. Practice asking for it. Know you will be denied. It’s okay. It is work to learn to advocate for ourselves - no one else is going to do it for us. And our clients need to see this work in action. They need to see that we ask for money and that we fight for money and that we deserve a bigger piece of the pie, just like they do. If you get denied, ask why. Look at the budget of your agency, and do your own math. At a local university, adjunct social work professors make half of what adjunct education professors make. HALF. Is it because the school of education makes twice as much as the school of social work? No. It’s because that is what each Dean asked for. And the question then, again, is why? Why are the numbers what they are? You have a right to know and think critically about these things. If you work for an agency that makes $63 per session and you are making $25 of that, where is the rest going? It’s okay to ask and to know. Study the systems that you are in.

     Fourth, use supervision as your central self-care. It ought to be embedded into your job, and it is one of the major gifts that social work offers us - the transmission of practice wisdom and experience. Demand that you get supervision consistently and without interruption for at least an hour a week. Make sure that your supervision does not focus solely on task management, but rather on case conceptualization, systemic analyses, and theory development.

     Fifth, get into your own mental health treatment and find a way to pay for it with the help of your work. Talk about the need for it explicitly and normalize it in the environment that you are working in. If your deductible for mental health happens to be $5,000, ask your health insurance company why. What made them come up with that number? If the person you are talking to doesn’t know the answer, ask to talk to the person above them. Find out what the deductible is for your friend, and tell your insurance company that it doesn’t make sense. Then tell your employer that they have bought into a plan that makes it impossible to access mental health care, and without access to mental health care, you can’t do your job.

     And finally, admit to yourselves that something is wrong. Something is so deeply wrong. Something is wrong when we are losing children at the border who are seeking safety. Something is wrong when schools don’t have proper ventilation, when it is easier to get a gun than a prescription for an SSRI, when racial disparities help to fuel and fund a huge privatized incarceration system. And when you admit to yourselves that is wrong, free yourselves from the idea that you are what is wrong. 

     You are the most right thing out there. You paid to go to school to study how to be in a relationship that heals people. You remember the names of distant cousins of clients you only met one time. You cry when you know that a client graduated with their associate's degree after working three full-time jobs and doing sex work on the side. You are documenting it all in your notes and writing it down, and you are trying to make it alright and all right.

Dr. Danna Bodenheimer, LCSW, is the founder of Walnut Psychotherapy Center, and the executive director of the Walnut Wellness Fund. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field (The New Social Worker Press).