Enjoy the Silence

Some clients will talk your ear off.  The moment you pick up the phone or step in the door you learn to expect an onslaught of questions, queries, observations, gossip, laments and explanations.  It can be hard to get a word in edgewise.  We learn a lot about these clients thanks to their willingness to share (or over-share as the case may be).  As workers, we work over time to develop this verbosity into opportunities for meaningful and constructive conversations.

With other clients the opposite is true.  Getting a full sentence out of them may be like pulling teeth.  I have two such clients right now, each with a very different basis for their (relative) silence. 

One is a relatively new client to me.  She has a long history of schizophrenia and “non-responsiveness to treatment”.  Part of the problem is that her mother speaks for her.  So we try to meet outside the house.  Our meeting tend to go along the same lines every time.  I greet her, ask some general questions (what have you been doing this week?  Anything good on tv?  How do you like the weather? etc) , try to bring up items from previous meetings, ask about plans.  Sometimes there is a head nod in reply.  Sometimes a quiet one or two word answer, which may or may not be related to the question.  Sometimes a moment of silence followed by “sorry, what did you say?” 

I can see that she’s struggling.  She talks to the voices a lot more than she does to me.  Under her breath, so I can’t quite hear.  She pushes on her eyes, opens and closes them repeatedly without looking at me.  She puts her head up and down off the table.  She has a lot going on, and I do get the impression that she’s trying to be present for our conversation while all these other things are going on for her. 

Slowly it’s getting better.  She is maybe getting used to me, will ask me questions sometimes, will give me a few words more of response each time.  I’ve referred her to a new psychiatrist who I think (hope) might progress where the last one stalled.  I’m working with her family on letting her speak for herself.  We’ll see how it goes.

The other is a long-time client.  We’ve worked together about 3 years.  I’ve seen him through several ups and downs.  But the silence is a new thing.  It’s not even silence per se, but quietness.  I ask a question and he says something in response but the volume knob must be turned to 1 because I can’t hear.  I ask him to repeat himself and he may or may not.  Several times I’ve resorted to being blunt “I’d really like to talk to you, but I’m finding it hard to hear what you say.  Can you speak up?”  This goes nowhere.  When I can hear him, I’m not sure I understand the content.  It’s tangential, it’s rambling, the associations are loose, as they say. 

It’s an important skill in the toolbox for every good counsellor – being comfortable with silence.  We are often invading people’s private spaces, their homes, the personal lives with our assessments and surveys and mandatory home visits.  We discuss difficult and painful subject matters.  We inquire about things some clients never may have spoken aloud to another person.  Sometimes the reasons are unclear.

So what can I do in these situations?  Show up.  Keep talking.  Give them space.  Catch myself when I’m becoming frustrated.  I’ve got the luxury (ha!) of working in a long-term program, so hopefully I can give them as much time, space and talk as they need before we have to say we’re not getting any work done so discharge becomes necessary.

Any other ways you can think of to support a client who is having trouble communicating?  

The Long Haul

How do you help a client who has been the recipient of case management supports for 14 years, and does not yet understand why she is receiving the service and what is its purpose? She can tell me exactly the number of visits she’s had (108 from me over the past 2.5 years, 784 total from all CM’s) but not why they are happening.

Careful of becoming frustrated, I go into empathetic mode. “You seem to have some questions…” “I hear that this is distressing you…” “Is there help you would like that you don’t feel you are getting…”

I’m not sure she hears what I say, as she would like to reinforce her previous statements, and repeats what she’s said before I am finished. Then repeats it again. We are testing the limits of the “recovery model” profoundly here.

So I call in the reinforcements. Her “natural supports” (dad) to keep him in the loop. He really wants to help, but doesn’t always know how. The “formal supports” (housing provider) to give a heads up and some background on the angry and frustrated phone call(s) they will inevitably be receiving. My supervisor so I can check my feelings about the situation, and get the help I need to figure out clinical solutions that may work here.

I really do believe in recovery. A situation like this makes me wonder if there was a failure in the system along the way, something early on perhaps that did not help this person gain understanding and a sense of control over their life situation (answer=probably). Perhaps it’s the set up, the fact that by accepting a rent supplement, she is bound to the “support” aspect of supportive housing. This policy has always troubled me as it is so far from “recovery” based.

On the other hand, maybe this is what recovery looks like for her. She’s been able to live in a place she likes for all those years. She has hobbies and things she likes to do, however sporadically she does them. She tells me she never wants to return to work, and does not want anything drastically different in her life.

Or instead, that could mean we haven’t done a good enough job of instilling hope and conveying a sense of what is possible.

Perhaps her journey is just a painstakingly slow long one. Maybe 14 years has just not been enough to create a new sense of self and new way of living after (what I understand to be) many years of neglect, abuse, illness and loss.

Sometimes it is just too hard to know.

Case Study #2

Client histories never cease to be interesting and surprising. Although I know we should always view our clients as a “whole” person who is dealing with an illness, when you have only known a person while they are SICK it can be easy to forget that they also have/had a LIFE.

One client on my case load is a 50-ish man originally from Vietnam. In the time I have known him, he has been very stable but somewhat “low” functioning. He struggles with comprehension, insight, and ADL’s. On the other hand, he’s got incredible financial management skills, and exceptionally beautiful handwriting. He hasn’t been able to maintain employment for many years at this point, although we’re working on that.

In the late 70’s in Vietnam, he was a young man studying physics and math at university. I knew from his hospital records and his own reports that he and most of his family came to Canada in 1980, and he had to leave university without completing his degree. He was diagnosed with schizophrenia several years after immigrating, and eventually dealing with his illness contributed to the break-up of his marriage, and caused him to lose contact with his son.

Blame it on my youth, but I somehow never put it together that the time he talks about in Vietnam was just post-war. And he lived through whatever terrors that had brought. Obviously I don’t have any details, but this all came to mind when I was listening to a recent CBC Rewind broadcast about Vietnamese boat people. This was his experience too. I don’t know if he came on a boat or what, but I know he was sponsored by a Mennonite group, who were among the earliest supporters of the refugees.

Knowing this will not likely do much to change how I work with this person week after week. And I understand that this general knowledge doesn’t provide any insight as to his individual experience. But it does provide me with some new perspective when he talks about his past. And it’s a good reminder (for me) just to keep in mind that this guy has had struggles other than trying to keep his kitchen clean.

Case Study #1

A bit of a backgrounder on barf-bag guy.*

Dude was a hard rocker in his younger days. Played sports, partied hard. Drank a lot, used marijuana and coke. As an adult got a decent job driving a forklift, and enjoyed watched football with his drinking buddies. He’s a big guy who loves beer and greasy food. His parents both died fairly young of cancer, leaving him extremely broken, a feeling he drowned in about a weeks worth of tequila after the second funeral.

Eventually, he got married to a woman with a young daughter whom he loved like his own. A couple years in, his wife comes out as a lesbian and says that she and the daughter will be leaving.

This is just too much for him, and so he slits his wrists, getting himself an all-expenses-paid five day trip to the hospital. He comes home to find that his family has indeed left with most of the couples belongings, including several pets. They kindly left a pile of debt in their wake. So, here comes the second suicide attempt, the wrists again. Hospital stay, take 2.

Long story short, the guy lived, but did a number on his wrists, leaving him with limited feeling and movement in his hands. Years of sports and hard living have taken their toll too, resulting in bad knees, back, shoulder, and carrying around an extra 200 pounds or so. He wasn’t able to work after the separation and the suicide attempts due to his rapid decline of physical and mental health. So he winds up on welfare, then gets disability support, still hardly paying enough to look after himself in a healthy way.

He’s doing reasonably well now since he got a government subsidized apartment. He meets with his counselor, has a few friends, and is good with is money.

But this man is only 45, and looks at least 20 years older. He can now barely walk, is in all kinds of pain, has a myriad of GI problems (ick) and still deals with depression.

He’s a smart and nice guy with a good sense of humour, but I often feel at a loss of how to support him. How do I work with him to accept that he is basically like a senior citizen? That he may need some in-home care, a pass for the wheel chair bus, and some serious medical interventions?

Really, he knows all this. But he also does not want to give in, and has sort of resigned himself to suffering. I totally believe in a client’s right to self-determination, but it doesn’t make it any easier to watch. I’m trained to cope with and offer support to people in all kinds of mental and emotional distress, with whatever social factors working against them. But physical deterioration? Out of my scope. We’re meeting with his GP this week, and I’m anxious to see how it goes.

*and no, he didn’t end up puking in my car. We had to pull over for him to get some air, but fortunately it didn’t get any grosser.

Got a pile o'problems

I was catching up on some old posting by one of her posts put me in mind of a story of one of my clients.

There seems to be a lot of talk about hoarding lately, recently brought into the spot light my such shows as