Up In Smoke

It's got to be one of my least favourite thing about my job - my hair and clothes smelling like smoke after doing home visits*.  Many clients are courteous, and don't smoke while I visit.  Some just find it too difficult to  it though the appointment without smoking.  In summer we often accommodate this by meeting outside.  But it's currently winter here in Canada, and temperatures are too cold for that.

Some job postings in this field state that the candidate should be aware they will be in smoking-environments.  Mine didn't but I've long recognized it as an unavoidable workplace hazard.  Sure, if I really wanted I could try to insist that clients meet me elsewhere, but the home visit plays an important role in my work, puts focus on me rather than the client, and possibly makes them feel guilty.  That's not what I'm trying to do folks.  Besides, it's their room/apartment/house.

Not so fun fact: rates of smoking for people with schizophrenia are estimated at about 88% - three times that of the general population.  And smoking cessation is just not high on the list of goals or priorities for most of my clients, who are busy trying to manage their symptoms, maintain their housing and survive on a few hundred bucks a month.

So until this changes, you'll see my huddled in my big coat and hat, driving with my windows down in winter trying to air myself out.

*not every home visit.  About half my current clients are smokers

What Makes Me Happy

This is about a client I had when I first started this job. I may have reflected on this story before in my blog, so bear with me if it sounds familiar.

He had been in the system for years, and had previously been supported by a coworker who left for another job.  He was a young man with schizophrenia and developmental delays.  He lived with his family (who wanted the best for him) including his grandmother who brushed his teeth for him even though he could do it himself.  It is fair to say there was a lot of learned helplessness going on.  

I was a little more eager and a lot less experienced then.  This man was more ill than anyone I had worked with previously.  My normal tactics did not work.  We were down to real basics - getting him to remember who I was, and remember his appointments.  Our appointments consisted of me trying desperately to make some kind of conversation while he was more interested in watching soccer or getting me to take him out for pizza.  All the while granny is knitting in the background and making me hyper aware of my youth and inexperience.  

I don't remember what the incident was, but somehow he ended up in hospital.  The family and I worked with the doctors to get a med review and he was started on Clozapine.  While he was still admitted I advocated to get him in with our ACTT program (Assertive  Community Treatment team - a more intensive level of support than what I provide) and he was accepted, so I never really saw him after his discharge from hospital.

Until one day I was in the waiting area of a psychiatrists office with another client.  I recognized this man's sister and then he came out from his appointment.  He looked me straight in the eye and said "Hi Nectarine" and then proceeded on his way.  

That was it.  But it was so much!  This person, who had met me at the door with a blank face week after week, giggled when he couldn't remember my name for months over a year prior at this time had said HI and addressed me by name!  He now attends one of our drop in programs and I see him over there from time to time.  Every time this same thing happens.  He says hello to me the same way, and then walks away.  It's all I'm likely to get, but it's so much.  It makes my day every time.  

Will this client continue to recover?  Probably.  Will he recover to a level that other people find "normal"?  Probably not, but to me, all the work he and his supports have done is so worth it to bring this human being out of the bubble his illness and medications had put him in.  I'm grateful to have been a small part of it.

The Greatest Day

Client quote of the day for sure:

Client: It's the greatest day of my life!  I can't hear anything anymore!
Me: What? You can't hear?
Client: I can't hear the voices anymore, they're gone!

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?  

Facts and Feelings

"[Client] has a daughter [name] who is in the care of [client's] mother in Thunder Bay. [Client] reports having no contact with his daughter, and states that he does not wish to have contact. [Client] has indicated that he thinks she is being well looked after and does not wish to disrupt her life."

This man's wife committed suicide in 1999.  She had schizophrenia, as does he.  I suspect any reminders of her are just to painful.

Sometimes when I stop to actually read what I record in my notes it just makes me sad.

A Day in the Life

Thursday February 3, 2011

8:30am – park a block away from first appointment and check messages on office phone and cell phone. Remarkably few, possibly due to yesterday being a “snow day”.
9:00 – pull up to client’s building for first appointment. He’s a big guy (with severe back, neck and knee problems) who struggles to get in my little car, but we make it. We head off to check out a new grocery store, a figure out a route for him to take the bus there on his own next time.
9:45 – take same client to coffee shop for a caffeine fix and quick chat about plans for next week’s meeting.
9:59 – return to client’s building, help him load his groceries in.
10:00 – back in the car, call the pharmacy to see if next client’s prescriptions can be made ready for pick up. Ah, crap – there are no more refills. The pharmacy offers to fax a request to the doctor’s office, and I call the client. He swears that he did see this doctor in the past few months (can’t remember exactly when, but…) and forgot to ask about those prescriptions.
10:10 – Call the pharmacy back, they say it might take awhile. Call the client again, tell him it might take awhile and is it okay if I drop his meds off this afternoon. Yes, that will be fine.
10:20 – Eat my lunch in the car trying to ignore the fact that it’s -10 Celsius outside but I’m dressed in several layers so that’s okay. Relish the fact that I have a few minutes to listen to Q on the radio.
10:45 – Head downtown to start searching for a parking spot.
11:00 – Find parking, dash across the street to the church to set up for the Outreach lunch program. My co-facilitator has beat me there, as have several of the clients, even though we don’t officially open until 11:30, but hey, it’s still -10 out!
11:30 – Serve chili, chips, and veggies to familiar faces, and some new ones. The attendees are mostly male, 40+ and kinda rough around the edges. They make loud conversation about politics, people they know, their plans if they won the lottery, and “the way things used to be”. They’re a good natured lot, and the lunch tends to run a lot more smoothly than its breakfast counterpart at the other church. Breakfast gets a bigger crowd, and there is sometimes “trouble”.
12:30 – start tidying up as people leave. Spend some time supporting an elderly couple whose son lives out east and was recently diagnosed with bipolar. They’re frustrated that “the system” out there isn’t giving him the support he needs, and they wish they could do more to help. They went to visit him last fall when he was in the hospital, but the motel was expensive, and it’s hard for them to travel.
1:08 – I realize that I’m late for my next appointment, and try to call but get the answering machine. The outgoing message wishes me a “happy new year” and remarks about the date 01/11/11 for several minutes before cutting me off, so I don’t get to leave a message.
1:15 – I arrive to my “happy new year” client’s building, but there’s no answer when I buzz the intercom. I wait inside the front door for several minutes then try again. I call her phone, and the answering machine seems to work this time so I leave a message asking her to call and reschedule.
1:30 – Back in the car, I drive to the neighbourhood of my next appointment, and park across the street to check messages again. One marked “urgent” from a new client whom I have met only twice telling me that he found a room to rent and is no longer living in the shelter, and he’ll call me later to set up an appointment, because he doesn’t have a phone. Another from a current “high needs” client crying and upset because she’s lost all her ID. This could be pressing, but I know if I call her back it’s possible I’ll get stuck on the phone for a long time so it will have to wait for a more opportune moment.
1:40 – I check my email and notice a message from a client I did an intake with a couple weeks ago. He let’s me know that his housing arrangements “didn’t work out” and he, his wife, and their two children are now in the family shelter. He sounds pretty desperate for help and is planning to rent a truck to go sleep in. I remember him as extremely depressed, anxious, and suicidal. I email him back quickly to ask if it would be okay for me to refer him on to our outreach program which can meet him right away.
1:55 – I call my 3:00 to see if we’re still on because he often cancels. He has schizophrenia, and is also going through cancer treatment so he’s not always in the best of shape to meet. He asks if I can come earlier than planned and I say we’ll see.
2:00 – I check in with my next client. It’s dark in her apartment as the balcony door is blocked by the snow and she never opens her curtains. She finally let her dad know that her cat died, so he’s not worried any more about why she’s acting out of sorts. She missed her psychiatrist appointment last week because she’s scared that if her taxi runs out of gas it’s winter and she’ll be stranded in the snow. She’s scared that no one will save her. I try to understand, and try to support as best I can.
2:30 – Back in the car, call Mr. 3:00 and let him know I can come now. He wants to go to the grocery store and has his list ready.
2:35 – I pick him up, and off we go.
2:50 – I’m getting a grocery cart while my client starts his shopping inside. An older gentleman is trying to light his cigarette with a burnt out lighter, and I suggest to him that he’s probably not allowed to smoke in here and needs to go outside. He asks me for a match, but I don’t have one. He goes back to trying the lighter.
3:45 – Groceries are done, and after a stop at the post office I take my client home. We make arrangements to meet next week if he feels up to it.
3:50 – In the car I call the pharmacy from this morning and learn they finally got the refills, they didn’t think they would cause this doc has said no before. I call my client to update him, message my boss to update her about the changes to my schedule/location (for safety purposes, understand) and head off to the pharmacy.
4:05 – At the pharmacy we commiserate for a minute, and they tell me my client called them about 20 times today, anxious about his medication. They’ve known him for years, since he was homeless down the street from their store, long before I came around. They want to know does he also need his foot cream, I call, he doesn’t, I take the bag of pills (these have got to be worth $$$ on the street!) and zip over to his place.
4:20 – I get there (just in time) hand over the drugs and apologize that I won’t be able to stay and chat. I’ll call you tomorrow to schedule a check-in appointment, okay?
4:30 – I finish my day on time somehow, and call home to let them know I’m on the way.

I can't believe I made it to...

Seriously.  I really didn't know if I would stick to it with this blog long enough, but I'm glad I have.  I still find it cathartic and enjoyable to post into the great nether-world of the web my daily notions and mutterings to an audience of whomever happens to stumble across it.  That's good enough for me! 

I thought that to mark this special occasion, some good news was in order.  Edmond Place in the Parkdale neighbourhood of Toronto will be having an open house this week.  This remarkable housing project was completed in only three years due to community collaboration and support from the municipal government.  The project is named for Edmond Yu, a man with paranoid schizophrenia who lived in the building when it was a derelict rooming house in the 1990's.  He was evicted, and was later shot and killed by police when he caused a disturbance on a city bus.  The building suffered a fire in 1998 leaving many more homeless. 

I sincerly believe that supporting people with mental illness to stay safely housed can help to avoid such tragedies.  Of course there are other benefits as well - Saving money to the health care system, safer neighbourhoods, community and dignity for the people living there.

I look forward to seeing more projects like this.

Family Dynamics

So last week I received a referral from one of the hospital social workers for a new client. I called the social worker, because sometimes the client is still in the hospital, and we can meet them there. It tends to really increase our chances of a successful follow up.

This client had already been discharged, but the social worker gave me some additional background and his impressions of the client (patient in his case, I guess). He tells me that this client was recently diagnosed with schizophrenia. He’s a truck driver, lives alone, his family is all in the US, but they are very supportive.
His father is a psychiatrist. His sister is a doctor. The other sister is a social worker. His brother is a development worker.

And I can’t help but wonder how the onset of a serious mental illness would play out in the family dynamics. Is it more frustrating than usual for the family to feel like they can’t help him? More importantly, how will this affect the client? Will he feel that understanding and support from his family, or perhaps like a failure and an outcast?

I know that it is not unusual for families to be challenged or seriously disrupted by something like schizophrenia. Feelings of failure and disappointment crop up on both sides of the equation.

I know that most of us have someone in our network of friends/family/acquaintances who has a mental illness. I have people close to me who live with/have survived eating disorders, alcoholism, SAD and more.

This case just struck me as particularly potent.

Dear Random Social Worker,

Thank you for referring your client to us. We would have called you back sooner, but we have only just received the referral form. We likely would have responded more quickly if you had faxed or emailed it as indicated on the top of the form. Instead, you left it sitting out on a desk in our rural office, you know, the one that is only staffed part time, and is shared with another community group? I’m sure your client’s information is safe though since you had the forethought to fold the paper in half. And I guess you couldn’t have known that our staff who works in that office was on vacation for two weeks, so again, our apologies.

Now, I realize that you must be a very busy woman (aren’t we all!) but if it’s not too much trouble, maybe you could take the extra couple of seconds to write in your complete phone number? A bit of information about the client would be helpful too – maybe more than “needs support – monthly visits”.

Oh, and by the way – Primary diagnosis: schizophrenia/bipolar. Well, which is it? I guess the client may have both (poor thing) but then I’m guessing one of those is the secondary diagnosis, and it’s just a little hard to tell which considering how you’ve squished it all into the one little box there.

Well, I hear from your outgoing message that you are out of the office for the next three days (how nice for you!) so I guess I’ll call you back next week.

Ta-ta for now!

Get that "deep cleaning tingle!"

This was something I had never seen before.

I showed up the other day to see a client for a home visit and to drop off his medications which I pick up for him once a month. He’s an older guy with schizophrenia, who is also extremely obese. For the past year we’ve been working a lot on housekeeping and personal hygiene, both of which he has trouble looking after and issues which could put his housing at risk (there have been complaints to the building manager several times because of severe malodour).

We’ve had some great success of late. He has budgeted and scheduled for a cleaner to come once every two weeks and clean his apartment. He also got some help to install an air conditioning unit, which has really improved a space that I once had to leave in order to not pass out from the heat and smells.

So, back to the original point of this story – I show up the other day and he’s got blood all over his legs, from the knees down. I asked him what happened, and he says casually that his legs were itchy.

What?!?

I needed some more explanation.

Apparently, he had soaked his feet for upwards of two hours in a chemical household cleaning solution in an effort to get them clean. He said that he stopped, and realized this was maybe not the best idea when his feet and legs started ITCHING and BURNING. “The cleaning lady wears gloves when she uses that stuff” he knowingly informed me.

O. M. G.

He seemed very non plussed by the whole thing, but then, that’s how he is with most every thing. I pleaded with him to wash his legs with some cool, clean water once I left, and asked him to please call his doctor or get some medical attention if the itching or burning came back.

Maybe I should have offered to get him a proper pedicure kit for next time. Although it might be a little sore to use a pumice stone for while yet...

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.