I’ve got this image of The Insurer lurking in me, down deep where it’s dark and close and stuffy.He’s tall and hefty and ten plus years older than me. He’s got a crappy grey Men’s Wearhouse suit on, and old loafers, and a waistcoat: part Victorian banker, part Wild West accountant, part snarking lawyer. This is the guy who doesn’t just read my notes–he audits them, like a tax collector. He knows the DSM like he knows the Kelly Blue Book, which is to say much better than I. He doesn’t need to understand clinical realities, or working hypotheses; he doesn’t care about intuition. He looks at the facts, and he renders judgment.
This guy is built to push all my buttons, of course, because out in the back forty I built him myself: from the myriad of cultural images that reflect him to me, from my grandfathers, from my father. He’s frightening, he’s annoying, and he seems too wrong-headed… must I live with him every time I write a progress note? I so want to say, “no!”
It would be easy to dismiss him as a figment of my unconscious terrors, a device sent from my unknowable parts to provoke the growth of consciousness into yet another layer of the complexes he inhabits. He is funny, after all. Thing is, though, he represents something real–the reality that we must translate our therapeutic processes, after every hour of treatment, into a clear and linear narrative heading from assessment, to diagnosis, to treatment, and to outcomes. We are held responsible for all this stuff we do, and for good reason: what we do is real. It’s not interesting theories, and a chance to share them. It’s life and death. And the auditor–my demonic Insurer–that’s where he lives.
I met my auditor the other day.
She was actually really cool.
Because we have a contract with Albuquerque Metro Central Intake (AMCI) at my agency, we participate in a patient stream that allows us to treat people suffering from substance abuse and related issues. And because we do that, we have to abide by their paperwork standards. We do that, and we do it well. We are audited once per quarter. I made it through the last one with The Insurer perched on one shoulder, breathing his sulfurous breath into my neck. I dotted my I’s and crossed my T’s, feeling by turns pissy, rebellious, ennobled and exhausted. It took time to clean up my act, but I got it done.
And then I got to sit across from the person I’d projected so much of my inner work onto. No rumply suit. No loafers. She was certainly attentive to details, and careful to follow the linear trajectories of the narratives our notes added up to; but she was also practical, empathetic, kind, and funny. She was from Kentucky, where my wife’s family is from. She had service in her heart, as I do; she understood that the narratives we construct in our notes are not truth, but a provisional understanding, an attempt to find ways to support the patient in growing, one way or another. I trusted her immediately, and relaxed. The dark closet in which The Insurer lives got a little bit more spacious. Too bad he didn’t go away, says my rebellious teenager…
The Insurer is still with me as I learn, note after note, hour after hour, to report the bare-bones details of my patients’ cases, and to leave out the scores of details that hold the scents of further insight and growth. I believe I can continue to develop insight into him, but in truth, I need him. He helps me remember the stark reality of our work, the strength and humility that undergird my work.
Now I have a new conundrum to chew on: having learned to be more concise, I scratched open some grief: these notes we write are not like poetry or fiction or essays or blogging. And writing small and quick, I find I miss writing deep and long. I never knew that sitting in the therapist’s seat would reveal this limpid inner stream, this desire to sing it all somehow.