Anthony Bourdain

by Robert Lanz, LCSW

I won’t say my secretary Miss B makes fun of me to hurt my feelings, and it never does because I know we are friends. She’s a recovering addict and once told me, “Bob, you’re always the same. To me, that consistency is comforting. I see how you are with all he patients and I know that’s how you will be with me.”

That’s flattering. She’s seen me under the worst of circumstances with the most difficult people and all the emotional difficulties that come with major loss of some sort, aimed squarely at the guys in the front row: the SWs and the doctors. On several occasions when I was being threatened or berated by some broken person,  Miss B came out from behind her desk and got into their face the same way I did when I was a probation officer so long ago. I can do that as a probation officer in juvenile hall but it would be frowned upon my doing so as a social worker in a hospital. Still, I liked that she did it because it showed she was protective of me. Besides, I felt the same way she did, but under the circumstances, couldn’t unleash my fury.

But it wasn’t those occasions that she made fun of. Rather, it would be phone calls from what she referred to as “my patients.” She called them that because they called to see if I was on duty that night before getting themselves in situations where they’d wind up in the ER.

By definition “my patients” had perceptual difficulties, but they weren’t like the one-timers who lost loved ones or received a debilitating diagnosis or had near-death experiences. The regulars were the stoners, the homeless, the psychiatrically-impaired: the goofballs without structure, the brain-damaged or some combination of the above. Ask anyone who works in an ER: these are “social work” people. These are my people, and to many of them I’m “their” social worker: they have a perceptual reality like the one I have with my secretary. I find it equally flattering and I’m touched by it.

It reminds me of when I worked in the Family Treatment Program in juvenile hall. To many of those kids I was the dad they never had, the older brother they didn’t get, the adult that made the clear rules and enforced them fairly. Some of them continued to call me after their release from detention or took a bus down to see me, or asked if I could take them surfing or just have a talk. A couple of them even figured out where I was when I had Flaco’s Cantina in Utah and came up to help me out, chopping firewood and shoveling snow. That was very touching, too.

I came to understand those kinds of relationships over time out of necessity: if patients were coming to the ER to see me or one of the other social workers specifically, I wanted to know why. After a lot of thought and a little reading I figured out that in some strange way I was both an anchor and a flotation device to them: something they could hold on to when their emotional storms blew in. In their eyes, I was ensconced in the safety of a 500-bed hospital with a forty-bed emergency department and a social-work unit where they could become enveloped safely in. Once again, I was flattered.

My supervisor upstairs found out about “my patients” and called me up for a talk. I wasn’t concerned, because I was getting results with these “patients,” even if I was often unconventional in my methods. My supervisor mentioned the CEO of the hospital was aware of the positive happenings on the evening shift, and he was pleased. The CEO was a good guy and always seemed on top of his game, so I was pleased too. Nonetheless, I’m sure the financial bottom line was always a consideration — after all, he was the CEO.

Although social workers seldom learn any business skills in college and most of them remain satisfied spending other people’s money, I’m not that way myself.  Like any good businessman I want to know that my money is being spent effectively. As Dennis Miller once said, “I don’t mind spending my dough on the helpless but I do mind spending it on the clueless.” Regardless of what they taught us in graduate school, there is not an endless supply of money to fix everything all the time. If you think there is, you might have gone to grad school in the sixties when President Lyndon Johnson actually thought social welfare programs would end poverty in seven years and taxpayers could go back to spending their money on homes and vacations for themselves. But nearly fifty-years and trillions of dollars later,  we have more poor and dependent people than ever. But that is a rant for another time.

The emergency room provides, by law, the most expensive medical care money can buy. Yet a high percentage of ER patients do not even have a medical emergency or even an urgency. What they do have most of the time is some personal difficulty: medical, emotional, financial, chemical, or the like, and they are looking for relief. Absent a physical malady, they look to the social worker to provide that relief.

The form of that relief depends on the individual style of the social worker. Everybody is different, not everyone brings the same experiences to the table. Each brings their “self” to the party, with that “self” wrapped securely in the ethics, values and skills of a social worker. Maybe at your job you can’t always be “you,” but you can always be the “social work you.” That’s the anchor social worker; the flotation-device social worker, too.

For most of you, the first thing you do when you get in a car is buckle up and if the car doesn’t have a seat belt there will be some anxiety involved. I’ve been in plenty of seatbeltless third world taxis, and I assure you, it is disconcerting. When something can go wrong you feel a lot better knowing there is an anchor or flotation device to go to. So that is what I strove to become for those patients who felt unanchored and adrift or about to crash some time.

I’ve heard this story so many times I accept it as almost universal. Patients say they were at home, often alone, and started to feel dread or anxiety or suicidal or even hungry. The feelings remained unabated and over time overwhelmed the coping skills of the patient and they called for help. They call the ER and speak to the secretary to see if their favorite social worker was there. Sometimes they even ask the secretary to tell us they are coming in for a visit. She always told me, of course, at the top of her lungs: “Bonnie’s coming,” or “Joe” or “Mike” or “Lucille” or “that stinky homeless guy who plays the guitar.” Whomever.

The patients had the same tale: “As soon as I thought about going to the ER I started to feel better. When I got in my [car-bus-taxi-bike] and headed for the hospital I felt even better. When I saw the big red lights that said ER I knew I would be OK.”

The anchor was set and they felt better.

I often met those patients in the waiting room. If they had no medical complaints I could sometimes solve their problem right then and there: no expensive medical tests, no CYA EKG‘s — no taking-up an expensive bed when there was a cheap and easy fix. Maybe some talk therapy or some active listening or some fresh clothes, or, if it wasn’t too busy, a meal together in the cafeteria. If the patient wasn’t harmful to themselves or others and wasn’t gravely disabled, the patient could choose not to see a doctor. I’m an EMT and know the basic medical stuff, but I always ran my waiting room interventions past the doctors and triage nurse and no one complained about these chair side evaluations. Who would when the expensive and crowded ER is usually, well, expensive and crowded. I’m sure that is part of what the CEO liked.

Many times the patient’s presenting problem was suicidal feelings or hearing voices, too serious for a drive by in the waiting room, but everyone knew it was my patient and once the medical staff was finished with whatever medical workup they thought was appropriate it would be my call to admit or discharge the patient.

By having that anchor relationship I could often just ask the patient if they felt safe going home. If they didn’t I would arrange for the admission. If they felt safe, I’d hang out with them for a while longer to be sure and then have them promise to come back by ambulance if they changed their minds.

Sometimes I just needed to offer some direct provision of services like food or clothes or bus tokens. Remember my guy Richard in the Big Dick story? He’d come down for some fresh clothes every few weeks and maybe have dinner with me. Before he figured out that anchor thing he would fake some illness and use a valuable bed and other valuable resources just to get some clothes and a meal. When I confronted him about his ruse he apologized and promised not to do it again and he didn’t. He remained his goofy self and I have no delusions about his ongoing drug use and camping in the arroyo but as to his misuse of the ER, he kept the bargain and on some level we were almost friends.

There are a plethora of men and women just like him and they can be expensive or they can be less expensive if good social work judgment is used. And I know it is an anathema to most social workers but any employee should save the system more money than it costs to employ them.

Even my secretary knows that….

Dividing line


About robertjlanz

Author and health care professional.
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