Saturday, February 20, 2010

Darkness and light

My Dad doesn't know, but there are two defining childhood occupations that he introduced me to that were relatively critical for defining my own decision making and problem solving style. Oddly, both occupations happen in the dark.

The first occupation occurred within the (dis)comfort of the confessional. Sacramental reconciliation was an opportunity for self-reflection and getting back 'into good grace.' There was a ritual to the process that happened in the darkness of a closed and tiny booth - each week you had to 'face' the priest who could not see you and all the while pray to God that he did not recognize your voice! My favorite aspect of this was when you would say, "For these and all the sins of my past life I am sorry." It was such a catch-all point of relief - it was instant absolution no matter what. I wish my own kids didn't have to miss out on that feeling of having a 'clean slate' but this is not the way reconciliation is practiced in most places these days. This occupation of weekly penance taught me that even the most serious issues could be taken care of in a darkened room and a little humility and then a little prayer.

Not all problems are appropriate for the confessional - some required deep concentration, persistence, and just feeling your way slowly through the darkness. I learned these skills in trying to get 35 millimeter film onto a developing reel. I think I spent hours and hours refining the skill on a roll of developed film before I ever dared try with a roll of unprocessed film. Our method was probably unrefined - I would sit in the pitch blackness of the coat closet under the stairs with my scissors and can opener and developing tank. The coat closet was the darkest place in the house, even if it was not the most comfortable place to be practicing such a complex motor skill. Again, this is something that I regret that my own children can't really experience - they are living in a world where pictures can be taken without consideration of wasted film and wasted developing costs. But for me, when an issue can't be solved with quiet prayer I can always turn toward persistence, focus, and taking a slow and methodical approach to the problem - especially when I can't 'see' the answers in front of me.

The point to all this is that I always seek out the dark when I have large issues to contend with. I guess you could say that it is easier for me to find the light after I have spent a little time in the dark.

Tonight I drove out to the beach in Fort Lauderdale and spent some time staring into the blackness of the Atlantic Ocean. I was thinking about my Dad, and I found myself stretching all the way back home as I stared into the water.

Two miles north of my hometown is the third tunnel on the railroad line that parallels the river - it is the shortest of all the tunnels and is called Flat Rock. I am not sure how many people know this.

I know this because there was a time when I spent nearly every weekend down at Flat Rock - which was in our terminology not the tunnel itself but the opening of Annsville creek into the Hudson River, just south of that tunnel. It was just undeveloped land, perfectly hidden away from adult supervision - a sanctuary and teenage hideaway.

The nights at Flat Rock would get very cool, just like tonight. The breeze off of the river would always add that extra edge to the temperature, but the temperature was rarely noticed because at that time it did not matter.

What did matter was sitting at the water's edge, staring into the bonfire, and communing with the friends there.

At night the lights from across the creek would reflect into the water and lengthen across the river, stretching out and away from their source and toward Flat Rock. When you looked out into the night, fighting off the chill of the breeze and the cold drink in your hand, you could look across the water and see those lights, knowing that there was something out there for you, an answer reaching for you, beckoning you to come.

Walking along the ocean tonight I felt that same temperature in the air and felt that same gentle breeze. Closing my eyes, feeling the water around me, I almost made it home - stretching back into time almost thirty years. Maybe I could find some answers.

But opening my eyes just slightly, straining to see those lights of Flat Rock, there was nothing for me to see as I stared into the empty blackness of a cloudy, dark, and hazy sky.

For a moment I just didn't know what was out there any more. But then I knew I could solve these problems in the darkness.

It took just a moment, but then I thought about the confessional and how prayer helps. Then I thought about the coat closet and how persistence and method helps. The thoughts comforted me, and gave me enough strength to imagine a light house on the water. I could use a little light, I imagined - and what better way to find light in a black ocean. Then I also remembered that even lighthouses have a period when the light seems to flicker - when really.. it simply needs to go full circle again.

I am blessed to have received such amazing lessons even though I have to remember that I learned them sometimes. I know that I should not be amazed, but I still marvel at the number of times you can lose and find yourself within the same lifetime.

Thanks, Dad, for teaching me lessons that stick.

Thursday, February 11, 2010

Are we focusing on the best things so we can improve our early intervention program?

The value of anecdote is not in capturing a comprehensive analysis of a system's problems - but rather in making an example of a small issue that reflects a broader pattern. I understand that use of anecdote as a tool can also be fundamentally incorrect or even dangerous but I hope that I have documented enough other information about the early intervention program (in places like here and here) so that this presentation will be honest and fair.

I also understand that any 'for the children' rhetoric causes large swaths of people to immediately tune out of a conversation but it is difficult to frame this discussion about early intervention services outside the context of how it actually impacts children and families. The truth is that the future is a little uncertain about early intervention services in New York State.

Today's anecdotal evidence comes from this situation: one of my therapists had to write a progress report for a child who is enrolled in the early intervention program. Before submitting the report I reviewed it and found it to be satisfactory. I saw the statistical notations in the report and internally cringed - but we are mandated by the State to use certain guidelines for determining eligibility. I accept this; I need to function within the system even though I don't always agree with the way that the system is set up.

Anyway, through absolutely no fault of the person receiving the report, it was noted that a word was omitted on the paperwork. Now I don't imagine that this person has some particular investment in such technicalities of diction, but it is the person's job to make sure that things are done the way that they are supposed to get done. So, the report was sent back to us with the friendly request to include the missing phrase.

The error was that it was not adequate to state "Thirty minute session." Instead, the correct diction needed to be "Thirty minute basic session."

Now before anyone begins to worry that perhaps the word "basic" has some particularly discriminating function in this context - let me make you an assurance: in early intervention terms in NY State, a "basic" session MEANS THE SAME THING as a "30 minute" session.

Making such a change is really not that big a deal - and as I said I really am not impugning the worker who sent the report back to us for editing because after all they are doing their job and actually doing a rather good job to notice the error.

The problem is that there are things that could have been criticized in the report - most notably the statistical eligibility criteria. The worker might also have noted that in this particular situation there were complex family factors that might merit team discussion or planning. None of that happened though - and instead the concerns were reduced to having to make edits to satisfy the inexplicably tautological documentation rules.

Now I know better than to enter into a conversation with the worker about how inane the situation is - because after all I really do respect them and as I said they do a fine job - and they are also doing what they are supposed to do!

But what if someone suddenly stood up in the room and asked the question: "Are you all focusing on the best things so we can improve this system?"

The system is enormous and complex and rather uncaring of single voices most of the time - and as with all bureaucracy I think that is how it sometimes gets reduced to inanity. We all have a chance to give our input though. There is some new rulemaking being proposed for the Early Intervention program and there is an opportunity to provide feedback.

The issues are big and there are so many to choose from. You might go and ask that the program only employ practitioners who pass national certification examinations. You might go and lobby about consistent entry and exit criteria for the program. You might go and express some concern about parent co-pays and ensure that we only ask for contributions from people who really have the resources to contribute. There is a lot to be concerned about - and maybe if enough people go we can get to substantive issues.

I'll be at a public hearing. Maybe I'll see you there too?

Monday, February 01, 2010

The dangers of misinterpreting grocery carts when completing occupational therapy evaluations

During a conversation someone recently described a situation where they wanted to get a cart for transporting groceries from a car to inside the house. It was a phone conversation and I was listening intently, trying to understand what this odd device was that they were describing. They kept calling it a grocery cart and all I could think of was the cart that you use in the actual grocery store - that looks like this:

The conversation moved to other topics but later that day I got an email with the following picture, along with some gentle ribbing "Don't they have these where you live?"

As soon as I saw the photograph I immediately recognized the product and knew exactly what they were talking about - but the point here is that there was an initial block that made it impossible for me to understand what was being described.

First of all, if someone where I live had one of those they would have to push or pull it several miles just to get to the nearest grocery store. Secondly, it would need to have snow tires. In other words, given my current cultural context it just isn't something that I see or experience on a regular basis.

Certainly my cultural experience is wide enough that I have experienced those grocery carts in the past. Also, I like to think that if my specific cultural experience is narrow in parts that I can at the least imagine what people are talking about most of the time.

This all creates a dilemma in an evaluation context though. Today I evaluated a child whose family was from an inner city environment and I found myself making sure that I was listening really closely. My own experience is wide enough and I was familiar with the environment and knew how to understand the language and the issues well. This afternoon I had to evaluate another child whose cultural context was an extreme polar opposite of the morning experience.

I think I heard all of the issues correctly in both contexts. I think I communicated back to the families well enough in both contexts.

The shopping cart is nagging at my conscience though, and I just think that we need to be really really careful about our own cultural blinders when we do evaluations.