As a staff clinician at Cascadia Behavioral Healthcare, my writing largely consisted of assessments, treatment plans, and chart notes. I started out as many clinicians do writing notes that were akin to War and Peace, trying to capture every moment of the 50-minute session. But with ballooning caseloads there was enormous pressure to write short. My notes morphed into, “Client showed up. Depressed and anxious. Stable. Will return next week.” At least I wrote notes-some of my colleagues gave up under the strain and didn’t even bother. As one said, “I didn’t become a therapist to do charting.”
Eventually, I struck the balance with clever use of boilerplate. “Casually dressed, well-groomed he arrived on time unaccompanied. He made good eye contact and was responsive to questions with a pleasant demeanor. No suicidal or homicidal ideation. No psychotic process or substance use reported. Oriented times three with speech normal rate, rhythm, volume. Insight and judgment good.” That would be the objective part of the note for an ideal session. Throw in a quote at the beginning for the subjective part, a diagnosis and brief clinical formulation and then plan, and you’d have a classic SOAP (Subjective, Objective, Assessment, Plan) note.
Clearly not the most fulfilling writing but it fulfilled the clinical/administrative/billing/legal need to chart.
Community behavioral healthcare clients (there’s a debate about calling the people we worked with patients, clients, customers, consumers) were often struggling with so much adversity. Even before they were born, some had been exposed to alcohol. There were so many cases of child abuse. Lives with poverty, criminal justice involvement, shattered families, racism and other problems that made surviving with one’s sanity a tribute to resilience.
Over the years, I rose from staff clinician to site manager to manager of a couple of sites focused on depression, anxiety, trauma, substance abuse and personality disorders. I saw hundreds of clients and ran dozens of groups. An exhausting pace but often rewarding.
Then I was made director of staff development, in charge of training. I built that program over the years and was told by a Portland State University professor that it was the largest non-academic training program in the region. Cascadia had grown to about 1500 employees and close to 50 sites in four different counties. We offered dozens of trainings from HR basics like blood borne pathogens and preventing sexual harassment to dozens of clinically focused trainings. I supervised three people and we brought in outside specialists. I got to write dozens of trainings and became fluent in PowerPoint.
An amusing story--My daughter, then in middle school, was also being taught PowerPoint. I decided to let her jazz up my presentation. When I showed it to one of our IT people, the tech speculated that it would cause seizures. My young daughter had included virtually every special effect that PowerPoint could offer, with letters dancing, exploding, turning into ants and slides rapidly changing color and spinning off into space.
A not so amusing story--I was certified to teach a non-violent method of crisis de-escalation. It included a few techniques for breaking holds and grabs by aggressive patients. When I did trainings, I would ask the biggest person there to grab me so I could demonstrate that it worked. At one training, the audience member I chose grabbed me around the neck and had a psycho look in his eye. He was instantly choking me with all his strength. Fortunately, the technique worked. I broke his hold and stepped back. But I had bruise marks on my neck for a week where his thumbs had been.
I developed a good reputation as a trainer, doing trainings on mental health issues all over Oregon, in Washington, California, New York, and even China. The last one came when David Powell, an expert on clinical supervision, invited me to present at a conference at Beijing University. A very receptive audience, and fascinating to see how people have similar problems in such different settings. Or how things we take for granted, like privacy, were sometimes alien. Explaining the idea of Alcoholics Anonymous, for example, was a difficult concept for Chinese participants.
Then the Cascadia leadership decided to utilize my previous career as a reporter, and I became director of staff development AND communications. I was in my new position for a week when the company announced massive layoffs. Reporters came to me, most with a challenging air. But I knew both sides of the fence, even though I was now “a flack.” I played fair, spoke honestly, and while no one became my friend, I managed to develop a few less-than-combative relationships.
I did things like put out a company newsletter and a promotional CD. As well as press releases, responding to media inquiries, even driving the van and acting as tour guide when county officials wanted to view our sites.
Cascadia continued to grow and many speculated that it just got beyond the capabilities of the executive team. Or it was due to politics and conflict with Multnomah County, a major funder. The county ultimately decided to cut back on Cascadia, and we went from handling 80 percent of the county’s behavioral healthcare business to 40 percent with the balance being divided up among other non-profits.
But I stuck with Cascadia. I had a supervisor I respected and a great team I worked with. There were constant frustrations as we struggled with limited resources, but the pride that came with doing good in a difficult situation.
And I had my outside of work writing as an escape.