Confidential · Not Really · Everyone Should Read This
Case
Notes
Clinical documentation of an ongoing therapeutic relationship between one licensed macro social worker and his most challenging client.
Clinical Disclaimer · These notes are presented in compliance with HIPAA, NASW ethical standards, and the ancient tradition of telling the truth by making people laugh first. Any resemblance to actual historical events is not a coincidence — it is the entire point. The clinician is not licensed in the state of America because America does not yet offer licensure for the kind of work that actually helps.
Session 001
1776-07-04 · The United States of America
Presenting Problem
Client presents with grandiose ideation, selective memory, and a deeply ambivalent relationship with its stated values. Reports feeling "exceptional." Unable to define the term.
Affect
Performatively calm. Visibly sweating.
Intervention
Reflective listening. Clinician asked: "When you say All Men Are Created Equal, who did you have in mind?" Client requested a break. Break lasted 89 years.
Plan
Continue weekly sessions. Assign homework: read the footnotes.
Clinician's Note
"Client arrived 11 minutes late and blamed traffic."
Session 044
2008-11-04 · The United States of America
Presenting Problem
Client reports breakthrough. Elected a Black president. Immediately unsure what to do with that information. Half of client is crying. Other half is buying guns.
Affect
Dissociated. Both halves.
Intervention
Clinician noted the number 44 and paused for a long time. Client asked what clinician was thinking. Clinician said: "Nothing. Keep going."
Plan
Monitor for regression. (Spoiler: there was regression.)
Clinician's Note
"This was always going to be complicated. We knew that going in."
Session 107
2025-01-20 · The United States of America
Presenting Problem
Client has relapsed. Presenting with familiar symptoms: scapegoating, magical thinking, and an inability to sit with discomfort for longer than one news cycle. Reports that everything is fine.
Affect
Manic with undertones of exhaustion.
Intervention
Clinician attempted to establish safety plan. Client said it didn't need a safety plan. Client is not okay.
Plan
Refer to community. The community already knew. They've been ready.
Clinician's Note
"Clinician is also a client. This is what makes it funny. And also not funny."
Session 108
2026-04-02 · The United States of America
Presenting Problem
Client asked why it has been in therapy for 250 years and nothing has changed. Clinician said: "Because you keep firing your therapist right before the breakthrough." Client went quiet.
Affect
Something shifted.
Intervention
Clinician told a joke. Client laughed. For the first time in 250 years, something moved.
Plan
More jokes. Rigorous ones. With footnotes.
Clinician's Note
"This is the part where it gets good."
More Sessions Coming
The work is not finished.
Neither is the client.
The joke is the framework.
The framework is the joke.
Marc McAleavey, MSW · Comedian · Meta-Macro Social Worker