The following is an excerpt from some of my recent writings on Community Based work and part of a proposal for pilot programs in this mode of social work....
The shrill voices of children and the sound of basketballs rhythmically slapping the asphalt and ricocheting off the metal hoops and backboards and the soft yellow light of a late September afternoon surround me. I’m in my usual spot on this basketball court standing off to one side and out of the line of fire, relaxed, with my arms folded loosely across my chest, my feet slightly apart, dressed in frayed brown cords, purple polo shirt and an old pair of sneakers. I could be a coach.
I am the only white person standing in this vast contagion of mostly black and Puerto Rican youths that range in age from 6 or 7 to 19 and 20. I am a social worker and in the midst of this brightly colored chaos is my 8 year old client, Isaiah (not his real name), who I come here to see once a week for 50 minutes. Isaiah is diagnosed with ADHD, not by me, and he has learning deficits. He is a Special Education student and because of that he is assigned a counselor. He is also quite bright but few people seem to recognize that.
As the sun sinks lower into the urban twilight and shafts across the parking lots and sidewalks towards us it glistens on the beads of sweat on the foreheads of these youths as they chase the loose balls across the court and try again and again to hit the hoop. Some of them, boys and girls both, hit it with resounding success.
At the other end of the court the afternoon light has ebbed. Some older, black teens are playing there and in the shadows they are all but invisible except for the whites of their eyes and teeth and the softer white of their satiny, knee-length shorts. They are graceful and powerful as they leap, laterally and vertically, pirouette, then bend in pre-jump crouches and leap again. They can fly. They used to strike me as fierce looking. When I first started bringing Isaiah here for his therapy sessions they were as intimidating as I’m sure they were trying to be. They’d look right through me with fierce, cool gazes. Eventually a slight nod would accompany the gaze and then, mysteriously, after months, something bordering on warmth and acceptance.
On this evening I am not getting the ball much. Each week I bring several basketballs to the court with me. I bring a blue one with a Duke University emblem that my daughter won at Six Flags and several standard Nike and Spaulding reddish-brown ones that I’ve picked up at tag sales. This afternoon there’s also a red and white one, and a bright orange one, a few that are red, white and blue, out on the court.
The fact that I am here on the court doing therapy with an 8 year-old black youth and not in a small, cramped, agency office is astonishing. What is also astonishing is that as I become more experienced as a social worker I can feel the work I’m doing on the court with Isaiah impacting others youths that are out on the court. It’s similar to group work. I have some proof of this. For instance, I often run into kids that I see here each week, friends and neighbors of Isaiah’s, at the mall or at their schools where we run into each other by coincidence. They smile and come over to me, glad to see me, and we shake hands (a brief formality of mine that I impose despite some awkwardness). “Are you coming this Tuesday,” they ask? “Yeah, I’ll be there. See you then,” I say. We wave goodbye.
This is an example of Winnicott’s concept of “holding”. It’s also “attunement”, two meta concepts in therapeutic work with children who have experienced disturbances in their development caused by any number of things like neglect, abandonment, physical and sexual abuse, or profound loss, like death or separation, and the grief that follows loss, and who, at the time, were not resilient enough to cope.
Isaiah has elaborate defenses, like we all do, that he’s created over time to ward off pain, too much pain, or the memory of pain experienced in the past, again, too much pain. He isn’t all that verbal. He talks with his eyes and his body, shrugging, nodding, rolling his eyes, and he grunts yes and no. Not many of my young clients are verbal. It’s crazy when you think about it that I see these kids each week for one hour out of 168 hours in a week ostensibly to talk to them and they’re not verbal. That’s where the basketball court comes in.
Since anxiety is the key issue for most of these clients, actually all of my clients, I use what I call “Gross Motor Therapy”. I spend part of each session allowing the clients to “get into their bodies” which is a good method for quickly decreasing anxiety. There is an abundance of basketball courts in the projects and neighborhoods where I work and where it is safe to take my clients. Once they have a basketball and a hoop to shoot at I concentrate on just being present with them, observing carefully and learning. It doesn’t have to be a basketball. It can be a frizbe or a football to pass back and forth, or anything that gets them into their bodies.
“Holding” is a lovely concept. Winnicott uses the example of a young child at home with her mother. The mother is working around the house perhaps in the kitchen ironing and folding clothes. The child is playing in the next room with a doll. They are in close proximity. The mother is allowing the child to “be”. She’s not standing over the child telling her what to do. Neither of them feels abandoned by the other. They are aware of each other but can momentarily get “lost” in what they are doing and be independent of the other. Winnicott describes this getting lost as “unintegration” where the daughter is allowed to just be herself, allowed to explore herself, and who she is. (There’s a beautiful trreatise on this in Mark Epstein’s book Falling to Pieces without Falling Apart.)
On this late September afternoon I am “holding” about 30 kids on a basketball court. I’ve been coming here every Tuesday since May, since the days got longer, and I’m accepted here now. My role is established. I’m even trusted with secrets by the young girls that tell me about “nasty” boys that torment them and that they also have dreams about. So I consistently get myriad forms of validation. For instance, at 6:30 Dyiasha’s step-dad comes to say hello and take her home for dinner. Dyiasha is 8. She’s got a powerful pass and a good eye for the rim. When she shoots, she aims for the back of the rim, she told me. Sweat forms in beads across her brow. Her skin is very black and accentuates her eyes. Her look is serious. When she shoots her eyes have astonishing intensity. Her three-pointers are amazing for someone who is only 4’6” tall. She can hit one after another and make the boys howl with envy. She always looks over at me when she makes a basket until our eyes connect and she produces a slight smile.
Her father works for a cable TV company. He wears the company’s khaki shirt with his name tag sewn over the pocket. His skin is coffee colored and he has a gorgeous smile. He comes over to me and we touch knuckles, or we shake hands, and say hello. He’s crazy about Dyaisha and leaves me as he runs and tries to block her shot. She shoots past him, her shot misses and he gets the rebound, dribbles to the center of the court, shoots and makes an impressive swish shot. He gloats and Dyiasha groans.
During the past five months I have heard Dyiasha’s woes. They’re mostly about her immense sadness that began five ago when her mother and biological father split up, how much she misses him, and yearns to hear his voice. He stopped calling two years ago. She has accepted her new step-dad. She said she feels love from him and in many ways it is a more rewarding relationship than the one she had with her bio-dad. One thing she likes, she said, is that her step dad works and has money to do things with the family and he’s sober. He keeps promises. He doesn’t yell at or hit her mother. He is able to say “No!” to Dyiasha and her siblings. Like most kids she doesn’t like “No!” but she also says that he listens to them and talks to them and, most important, he’s funny and handsome. He’s a good father and it’s probably because he had a good father.
Dyiasha is one of the lucky ones. Most of the youths here and most, if not all of my clients, do not have fathers present in their lives, or, you could say, their fathers are present by their absence. My clients admit to me that they think about their fathers constantly. This is not the result of divorce. This is abandonment and neglect and it is deeply felt by the children of these men who, one day, just simply disappear. It is felt deeply by the women, the mothers of these children and by the community as a whole.
The impact is enormous. To say the kids yearn for their fathers is an understatement. They are constantly depressed and anxious because they fear they’re to blame for their father’s absence. The depression and anxiety takes on the form of ambivalence as they simultaneously grieve for their fathers and hate them for going. For the mothers of these children, the women the men leave behind to take care of the children, life becomes a living hell.
Some fathers disappear without even meeting their children, or they hang around just long enough to develop a relationship with their children and then leave. Some fathers have a child by the mother, leave for a year or two, come back conceive another child with the same woman and leave again. One mother I work with has had five children by the same man but in 19 years he’s never lived more than a few days with her, never given her any form of support, or spent any time with his children. A fairly high percentage of the missing fathers are in jail. A smaller percentage of them have died. In my list of clients there are only one or two fathers that are still connected with their families and it’s a marginal connection. Many of the fathers have started new families and still live nearby, or have just disappeared.
Dyiasha finally wrestles the ball from her step dad and he comes back over to stand beside me in mid court laughing and shaking his head. Isaiah throws me a ball he’s been using. In a way he is reminding me that I am there for him. I take a shot and miss. The ball bounces high off the rim and then out of bounds and I chase it up on to the grass and then dribble back to center court and try again. The ball actually rides the rim in a circle before it falls through the hoop. Isaiah and the others laugh at my good fortune.
The crowd on the court are impacted by my presence and by the presense of Dyiasha’s dad. It’s palpable. When he stands here with me he’s part of the “holding” that I am intentionally practicing. Neither one of us is paying attention to any one individual. I keep my eye on Isaiah a lot of the time but not exclusively. We’re attentive to many individuals in turn, tuned in to the group as a whole, watching the movement, we’re protective and supportive. The kids only have to look up and we’re there. Were like parents to all of these kids in that sense and as a result their behavior changes.
For instance, Isaiah, is much more attentive to others when Dyiasha’s dad and I are close by. Isaiah even becomes altruistic and shares the basketballs with others and in one case recently he patiently taught a young girl, Destiny, how to shoot. Destiny arrived on the scene two weeks ago and when I handed her a basketball she looked mortified and quietly admitted, “I stink.” My response was my “Yeah, right!” look that said ‘listen, I didn’t think anyone could be worse at basketball than I am’. Isaiah, hearing Destiny’s self-assessment came over and took Destiny under his wing.
In the past two weeks he spent an inordinate amount of time with her until she was finally able to make a few baskets on her own. I called this altruistic because he wasn’t flirting with Destiny or looking for kudos from me. He genuinely wanted to help her and knew how. Not that he is incapable of flirting. Today he has been flirting a fair amount with a third grader named Sadie who seems to like Isaiah reciprocally. He is showing her how to shoot and retrieving the ball for her when she misses.
Isaiah is aware of his behavioral issues, what it means to have an ADHD diagnosis. We talk about it often. He has specific goals to work on week by week. The most important part of the work with Isaiah, any of my clients, is our relationship itself”; how I “hold” him, and this means my respect for him as an individual, as a young human being and his right to his own autonomy. For instance, my employers constantly ask why I haven’t referred him for a psychological evaluation to see if he needs medication. It’s my professional opinion that he doesn’t need medication. Both Isaiah and his guardian agree with me. They are clear that they don’t want meds for him. I have reality tested their opinion several times to see what is driving it. Is their decision reasonable? Are they well informed? They seem to be in both cases and I will support them.
Isaiah’s sense of me, since I am his therapist, is that we work together on problems and the work is inclusive. We’re like a team. I am a therapist, a mentor, and a case manager who tries to coordinate community-based resources for him. I call it “community based” because it is done in front of others who are also involved in the outcome as well as the work itself. Anna Freud and Dorothy Burlingham took children who were orphaned in German concentration camps during the Second World War into their Hampstead nursery in London after the war. They developed a community-based model so they could work more effectively with these difficult children. They built an understanding in the local community, including anyone who might interact with these children, to understand the childrens’ issues and be able to build positive relationships with them.
It is pretty much accepted in the United States and other developed countries to think of the so-called “medical model” as the cost effective solution to mental health issues. This is largely because HMO’s are governing the way the work is done and because there is a lot of money to be made today through prescription medications. Where ADHD, the Combined Type, used to be the single most popular diagnosis for clients Isaiah’s age in the US, Israel, Great Britain, and Italy, today it’s “Pediatric BiPolar Disorder”. BiPolar Disorder has become a billion dollar business for the pharmaceutical industry.
It’s getting dark. The kids are leaving the court in twos and threes. I love the way their dark skin blends into the twilight and accentuates their eyes and mouths. In the shadows I’m a white sheet of a ghost. At various times Isaiah has introduced me to his peers as his brother or uncle and I try to keep a straight face as the peers look from me to Isaiah and back again with a puzzled look and then I laugh as they get the joke. Within this group on the basketball court the range of skin tones is vast. There is such beauty just in the diversity alone as well as in the individual variations.
Dyiasha is on her way home with her step dad and they wave once more as I walk with Isaiah back to my car. The last few minutes of our session, now that he is relaxed, will be a recap of his week at school and a discussion of the goals we are working on around his hyperactivity.
We have measuring tools to track his progress that include day cards from his teacher. I work closely with Isaiah’s teacher, Ms. Gray, and we have a daily log, a check list, we pass back and fort that graphs his behavior. (Isaiah cleverly found a stack of the blank check list forms so that he was able to counterfeit his own “day cards”, giving himself perfect scores, of course, until he was found out.)We will take a few minutes to go over the ones from the past week. We also have rewards and consequences that we use to define and accentuate boundaries for him. His most coveted reward is a visit to Chucky Cheese for pizza and arcade-type games. I hate Chucky Cheese but it doesn’t make any difference. I will have to endure it as my price for the privilege of my inclusion in Isaiah’s community.
There is in this experience with Isaiah the sense of what “community” means. There is also a glimpse into what it would be like to have community based mental health services for children and families
To be continued……….
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2 comments:
It strikes me that the "medical" approach has also been aided by the lure of the line of least resistance that seems to be tugging on us all in these times of instant gratification and nano attention spans. It's much easier to prescribe and take a pill than to engage for the long-term and take the time necessary to build and rebuild relationships.
It astounds me that the medical community and all its collective wisdom can be led to believe that problems rooted in deteriorated relationships can be treated chemically and "cured" with rounds of pills.
Anyhow, I'm inclined to think your "community-based" approach may not only be the best but the only path to a psychologically healthier society. And not only will "community-based" engagement benefit the individual (like Isaiah above), but the interactions will directly benefit the communities themselves...regardless of the outcome for the individual. In other words, I think this has as much to do with the process as it does the result.
When I see you fathers standing on the court, I see you holding those who are in-play. The two of you together the reality of the Other in dynamic tension with the fantasy of the net and hoop, guarding the possibility of un-integration and integration.
When I see the two of you on that court I see the children watching you watching them and then seeing themselves through your eyes and thinking in whatever moments of clarity there are about how they move, how they treat others, how others treat them. I see them thinking about themselves and who they are in relation to you and who you are in relation to them.
When I see you on the court I remember a scene that took place almost forty years ago, a scene long described to me by my mentor, now 70, who answered 'yes' to a child, he met with each week at the park who asked, 'will you be here forever?'
As so often is the case the truth of the cost-effectiveness of medication does not hold across the range of mental health issues. An approach that limits itself to chemical interventions, especially those that include hospitalization, is ultimately more expensive than long-term, ongoing, community-based approaches, because, as Dan and Audrey say, the underlying issue is the deterioration of relationships, not individual mental health. Mental health issues will not disappear as relationships develop, human beings are naturally prone to all kinds of functioning, but the issue ceases to be how well are you functioning and become how are we functioning together. The community's ability to respond dynamically to an individual's functioning may decrease the dysfunction of everyone.
When I see the two of you out there on the court I'm also aware of a profound feeling of loneliness. A feeling with deep roots, not just 'where are the other fathers?', but also, 'where did they come from?', 'how did they get here', 'what is the story of their origins?', 'who are their ancestors?'
When I see the two of you out there I feel anguish, and a longing to join you, two proud fathers alone in the midst of an empty sea. What has happened to all of our histories?
I think a task for us, as social workers, in this century is to make an attempt at stemming a tide of forgetting who and where we came from, what our people went through, what they did to others, what was done to them, back as far as we can go. I think the role for us, as community-based social workers, is to extend relationships into the past, present and future, to make attempts at re-establishing connections to both wanted and unwanted pasts, to build a sense of belonging. I think when we value relationships as a factor in healing those relationships should extend in as many directions as possible. Maybe an attempt at it will bear fruit at some other time, in some other place.
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