Sending out an SMS

I have been supporting a client for the past month and a half exclusively by text message.  Has anyone else done this sort of thing?  Usually we would discharge a client if we went more than 30 days or so without face to face contact, but in this case the client is at a high risk for suicide, so we wanted to try and stay connected any way we could.

And it seems to be paying off.  He finally consented yesterday to go to a hospital - not just any hospital mind you, but one hospital in particular, in the next city.  If we could send him in a taxi (not something we normally do) and if I could guarantee that they would admit him, and guarantee they would be "better" than the other hospitals in our area.  I told him no way I could do that, but I did get approval to send the taxi.

I'm glad I did.  The admitting psychiatrist actually called me this morning to get some history and let me know my client would be admitted.  This is unprecedented!  Last time I sent out the local Mobile Crisis team and they took him to our local hospital, they had discharged him before I even got back to work in the morning!  I know there are lots of reasons this may have happened, but it's still very frustrating and also compromised my therapeutic relationship with the client.  It's so rare that hospitals follow up with us in this way.  The psych even stated that he could see this client needs long term care more than a hospital stay, but was willing to admit him in hopes that we can facilitate that while he's in.

I love when things work out this way.  It remains to be seen of course what will come next with this client, but so far so good.  And after I worried that my texts were just floating in the abyss, probably not affecting him at all.  It's still not my favourite way to practice, but just goes to show any connection is better than no connection.

What a great start to my long weekend, happy summer everyone!

Eye of the Hurricane

For the first time in over 5 years, I have no clients.  I have officially discharged everyone that was on my old case list for my old job, and am waiting to be assigned the clients for my new job.  It feels kind of...weird?  I have work to keep me busy, but in the meantime there are few appointments to attend, no follow ups to arrange, and no messages on my voicemail (that part I really like).  I'm trying to take advantage of this time to get myself ready for whatever comes next.

Taking the Long View

I remember when I interviewed for my current job and was asked how I would handle transitioning to providing “long-term supports” - I was already working for this agency doing short term and crisis response work.  The director who was interviewing me stressed how challenging it can be for both worker and client to maintain hope, focus and direction over a long time.  I hadn’t really thought about it before, but must have come up with a reasonable answer, since here I am as a long term case manager.

I’ve now been in this role three, almost four years.  Some of my clients have been with me as long.  One of my very first clients has had problems with her housing situation since before I began working with her.  She also had mental health and physical health problems, family and financial issues amongst other challenges.  Basically, we both realized that until she had more suitable housing, it would be difficult to focus on her recovery, and I could basically only help her to “get by” in all the other areas mentioned.  Right from the get go I got heavily involved in working to address the housing problem.  There were family members, multiple agencies and her own issues to consider in this work.  What she needed was a first floor apartment (safety and accessibility issues) with three bedrooms (two kids of disparate ages and genders) in a particular area of town (so one child could attend a special needs school) with no carpet (severe allergy problems) and that would be eligible for the rent subsidy she receives (landlord would have to agree to work with that program, program would have to approve it and have the funds for it).  Like finding decent housing isn’t hard enough!

 

I won’t go into detail about all the ups and downs in this process over the past few years.  I will just say that a couple weeks ago, I got a call from a staff member at the housing agency.  I could hear excitement in her voice as she told me that she was looking at an apartment that she thought would fit all my client’s needs and criteria.  She could arrange a viewing in a couple days. 

The client came, kids in tow and looked around.  She couldn’t have been in the place more than 3 minutes.  It wasn’t going to work she said.  Why, I asked, as it had everything she wanted.  Did she want to take the kids to the park so we could sit and talk about it?  No, she wanted to catch the next bus, everyone was hot and she wanted to get home.

That was Friday, and on the Monday I met with her.  It went back and forth, she could see the advantage of the place, but there were certain problems…could she view it again?  I made the call and set this up.  My hopes were high, because I hadn’t even expected this much.  This time she came alone, left the kids at home.  Took a little more time looking around.  In my head I’m making plans about how to apply for grants to help cover the moving expenses, when I’m going to fit in an appointment to take her to get the key…the housing worker tells her she will need to know by the end of the day if she will take it.  I will call her in a couple hours to see what she has decided. 

When I do, she’s not ready.  Can I call later?  Of course I can.  This happens a couple times, until finally I tell her I can’t wait any longer and give her the housing worker’s number and tell her she will have to call directly.  I try to put it out of my mind as I go home that night.

Come the next morning, there are no messages for me.  It’s not until halfway through the day that the housing worker calls me to say that she will need a signed letter of refusal from the client, because she didn’t take the place.  The reason she ultimately gave was that the bedroom furniture wouldn’t fit.

I spent plenty of time that afternoon debriefing about this situation with my supervisor.  It’s times like these that it is difficult to remind myself of all those social work-y truisms – about client directed service, and individual right to determination and all that.  I will still be there to support this client either way, but I have to say I was mad.  As much as I can rationalize about her reasons, and empathize because of her history, I was mad.  Four years of work, for what?  I gave this woman my best and felt like it was totally disregarded that day. 

I know it’s not about me.  But this was one of those situations where BECAUSE I care, I couldn’t just forget about it.  It’s hard to think about possibly several more years of working with this client after this has happened.  This is where the long-term gets really tough.  This is where I start to feel tired and stuck.

The fact is, that what I need in order to keep going here are the same messages we use when talking about recovery.  Patience...hope...a willingness to fail in order to learn.  Finding the small successes that mark our progress.  Letting go of the things we cannot change.  Moving forward, because you can’t go back.  This is what will get me through the next four years of trying and trying again.  I can only hope that I will be able to inspire the same in my client.  After all, she is the one who must continue to live in her current situation.  And ultimately, she will be the one who determines when and how it changes.  Maybe I will even be there to cheer her on.

What it's worth, will it work?

Sometimes (often) we feel we just can't do as much as we'd like for clients.

One client of mine was facing particularly difficult financial straits this month for reasons outside of her control.  I offered to provide some grocery gift cards to help bridge the gap.  I was only able to get a $25 card, and felt a little sheepish giving it to her - I mean, you have a $0 bank account balance and need to eat for a whole month - how far is $25 bucks gonna go?  When we met again she told me she really appreciated my help and the card.  The day she went to the grocery store with it they had a "dollar sale".  How perfect!

Sometimes we worry that the situations our clients are facing are too difficult, and we worry about the barriers they face.

I helped this same client make a call for emergency rent bank help.  We were both surprised to find out how long it would take to complete the assessment and get help approved and processed.  She let them know the homeless deadline she was facing and they actually called her back really quickly.  She got in for an interview and to receive her money.  She called me several times that day distraught because it was a very dehumanizing experience for her.  But she got the money.  Got it to the landlord and secured new housing.

The next day the workers who called her back so quickly and processed her request went on strike.  If someone had not deigned to give her priority, what would have happened?  Sometimes when we think we face the impossible, the improbable happens.

When we work hard, sometimes it just might work out.

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?  

Forgive me...

...while I take this (small) moment to gripe.

Last week I (hesitantly) let my supervisor know that I am ready to pick up a new client, as I need to increase my monthly contact numbers.  Some of my current clients are doing well and decreasing their support.  She pushed me to take two new people, but I insisted on one for now and letting her know by weeks end when I would take the other.

Monday morning we received an email that one of my co-workers will be off for an indefinite period, and her clients will be reassigned. 

So I got three of them.

*headdesk*

I'll be okay.  And I sincerely hope my co-worker is alright.  Just needed to whine for a minute.  I'm done now.

Circle of Care

Earlier this week I joined a client during a CAS (Children's Aid Services) intake interview. It took over two hours. I was the one who had called CAS in. She was aware that I was going to do so, and was more or less okay with it. She's had involvement from them before, and wants to get the help that she and her kids need.

As much as she's on board with using services and accessing supports, I still can't help but sigh when she starts signing consent forms and there are 7, 8, 9 or more of them.

There is a fine line between helping, and invading somebody's life. I fear that line fell closer to helpers number 3 or 4. Maybe 5, but definitely somewhere way before 10.

Breaking Up Is Hard To Do

I’m breaking up with a client. At least that’s what I’m trying to do.

I’ve been seeing her for two and a half years. I picked her up from another program, and she has had case management support since 2002.

She doesn’t need me anymore. She’s said as much herself: she’s got an active life in her community, great family and professional supports, medication that works well for her. But she sticks around because she wants a ride. I drive her twice a month to her trustee, which is a fair way from her house.

This arrangement made sense when she started it with her previous case manager. She needed help not to miss the appointments, and to understand the information she was given when there. But not any more. She’s had time to learn and get used to the process, and she can do it by herself, but doesn’t want to. I can hardly blame her. Why spend money on a taxi when you can get a ride for free? And taking the bus is a pain. That, and the fact that my “support” is tied to her housing makes it difficult for me to disengage.

This is the bigger (systemic) problem. More and more the focus in community mental health services is on “recovery” and this is definitely the right idea. People don’t need to stay sick forever, and support from people like me is supposed to help. This woman has had an incredible recovery, but as it stands our supportive housing program provides no exit as long as she relies on the rent subsidy. I would never say that her subsidy should be removed before she can afford it, as having safe and stable housing is obviously a huge contributing factor to keeping her well. She can afford (IMO) to do without me.

After having explored this issue from every angle with my supervisor for months and months, examining myself for counter-tranference, and trying everything to be sure we were not under-serving her or missing ways that we could connect or provide support, my supervisor told me that I have her backing to start withdrawing transportation support. I have no desire to leave her high and dry, so I will propose that we agree on a timeline in which we can develop a new transportation plan and then I will stop chauffeuring driving her. I began practicing in my head how the conversation would go, and how I will handle her possible reactions.

I went to pick her up yesterday. She was dressed very nice and had a big smile on her face. I wished her a happy belated mother’s day and she thanked me. Then she informed me “and it’s my birthday today!” Oh crap.

I couldn’t do it. I couldn’t rain on her birthday parade with my difficult news. Put plainly, I chickened out.

We meet again in two weeks. I’ll do it then, I swear. Otherwise, I know I’m only prolonging the pain.

The Wait

I’m still building up my caseload since I finished my Intake job. While doing intake, I supported nine people. Since February, I’ve had my numbers go as high as 16, but they now rest back at 14. It seems like every second person who get assigned to me has disappeared, or doesn’t want to engage in service beyond 1-2 visits. I guess it shouldn’t be surprising considering in most cases they’ve been sitting on a waitlist for over a year.

I really didn’t think it would take this long. I guess neither did they.

I wish

Me: The waitlist for case management is about 6 months to one year.  I'll call you by next week to let you know if you've been placed on the waitlist.

M. Eager: So I start next week?

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.

Happy Belated New Years!

Well, New Year’s day has come and gone and so far 2011 has been a blur! I realized that I hadn’t christened the year with a post yet, and thought I’d better reassure you all that I survived the holidays.

A quiet couple of days in the office at the end of December let me catch up on a lot of backlogged notes and assessments, so I was able to start this year with a clean slate. Let’s see how long I can keep up, hmm?

There are some changes that I know will be happening this year, and some that I am hoping for. Let’s start with some things I can count on:
In 2011…

 I will be transitioning away from doing Intakes, and back to full time case management. We’ve already started gradually increasing my case load which has been at about half for the past year.
 Our new office will open (likely Feb or March) and although I am staying put at the old location, this will certainly bring a lot of change!
 I will have a new niece or nephew…we’re expecting to meet them any day now!
 Two close friends are also expecting, so there will be babies abounding.
 AM and I will figure out our next plans for the house and keep fixin’er up.
 My best friend and I will mark 20 years since we first played on the teeter-totters together. We plan to celebrate by getting matching tattoos!

Things I’m hoping for in 2011…

 Getting our financial ducks in a row. I need to book a meeting with our advisor!
 I WILL learn to crochet! As soon as I get some of my current embroidery projects out of the way.
 The job search shall continue. *sigh*
 I want to find a volunteer opportunity that we can do as a family – AM, the kiddo and I.

When I’m making these resolutions, I try to think of them the way I work with my clients to develop goals – they need a plan, and timelines. I’m getting there.

Here’s to a grand 2011!

15) Staying at a job for two years is a ‘long time’*

It’s hard to believe I’ve been at this job for almost two years now. I’ve worked that long (and longer) elsewhere before, but this is the first job I ever had providing long-term support to clients. Most of my caseload now has been with me for the entire time I’ve been here.

In the last two months especially, I’ve started to notice things in my working relationship with my clients which I think are the result of being able to have this on-going support. Clients sharing personal information because they finally feel comfortable. New insights being gained through reflecting together on the past two years of their life. For me, know what times of year are hard for a particular person, and anticipating triggering events. It’s kind of cool, and weird.

Not having done this before, I’m always learning as I go how to balance the intensity of my professional relationship with clients and my personal boundaries. “Relationship” doesn’t even seem like the right word. I’m more keenly aware as I work with individuals longer that the whole thing is so one sided. I’m uncomfortable with the unbalanced power dynamic, and yet it’s so necessary. I admit, I resent my clients sometimes for how much energy it takes to support them. But I know it takes a lot of their energy too to do the hard emotional work I put them up to.

In a few months the intake part of my job will end, and I’ll be back to full-time housing worker. I’m curious/anxious to start fresh with several new clients all at once. In that case, it’s a bit of a comfort knowing I’ll still have my old stand-bys to give me some (unconventional) predictability and a feeling of (sometimes) stable progress. Assuming I’m still here for them.

*See here

The Housing Worker’s Conundrum

Where I work, I am one of three designated “housing workers”. This means that my clients meet the basic criteria for our case management program* and were also at risk of homelessness (or actually homeless) thereby meeting the criteria for subsidized rent. Put it all together, and you’ve got Supportive Housing!

Supportive Housing can be really great for clients, because it is so much easier to recover in your mental health when you have a safe and comfortable roof over your head, and it’s easier to maintain your housing when you’ve got a dedicated worker (that’s me!) and program supports helping to keep you on track. I’ve seen it make all the difference for quite a few people.

The whole goal of Case Management is “recovery”. We are “recovery-focussed”. We promote “client recovery”. Although we provide long term services without a set discharge date, we expect and hope that we will support our clients to the point where they can do well with a decreased level of support i.e. we don’t want to be there FOREVER.

Eventually, this becomes at odds with the actual “housing” aspect of supportive housing. Just because a client can keep their own appointments, is actively volunteering in the community, has been connected with community supports and has learned how not to burn the house down does not mean that they can afford market rent. And if we remove their rental supports, this is most often going to cause some kind of mental health crisis.

Can you see where this is going?

A number of my clients fit in this category. They have toiled away with case management supports for years, and are doing very well thankyouverymuch. But there are no processes in place for me to withdraw from providing them with case management services, as it’s tied to their housing. In fact, their tenancy agreement states that I need to see them in their unit at least once a month. But they don’t want to let me in, because they don’t need me any more. Or they do want me to come, and I end up playing friendly visitor, or worse, having tedious appointments where I feel like some kind of safety inspector. It’s intrusive, and I always feel disrespectful of my client’s when I do this. Not to mention, it's a waste of everyone's time.

I get the sense that a good solution has not been reached because this is one of the remaining elements of fallout from deinstitutionalization. Supportive Housing my particular region has only been around about 15 years, so we're just starting to see clients as this point in their recovery. What I would love to see is a position created for a dedicated follow-up worker who could do occasional housing inspections with these kind of clients, and provide emergency support or referrals should they experience a relapse.

For now, I’m off to what I know will be another 10-15 minute appointment that will sound pretty much like this:
“Hi, how are you? Anything new? Mind if I look in your kitchen? Sorry, I’ll get out of your way now. See you in July.”

There must be other ideas or models out there. Any you know of?


*live in our catchment area, have symptoms of major mental illness, needs assistance in basic life skills/keeping safe in home or community/maintaining employment or vocation