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?  

Role Reversal

Confession time.

The past couple months haven’t been my best.  In truth, the February/March time of year are usually when I struggle most with how I feel.  So this year has been no exception.

When I get depressed I have trouble focusing, lack motivation, become short-tempered with people.  I get chest pains and headache and I want to sleep all the time.  Pretty standard fare.  I usually cope with this by taking vitamin d, getting exercise, going to bed on time and generally making sure I practice self-care. 

As you might suspect (or know from your own experience) being a mental health worker does not make me immune to these things or perfect at coping with them.  It also doesn’t make me necessarily receptive to help.  Hey, I’m the one who is supposed to be doing the helping, right?

That particular kind of thinking is ironically what seems to have helped get back on the upswing recently.  So far this year I had been feeling particularly low.  It was starting to cause a lot of stress for me and my family.  My partner, who has had to deal with much harder issues than me basically sat me down and had an “understanding” talk with me.  At first I felt resentful, in all honesty because what he was saying is usually what I tell him to do.  Who is he to tell me how to feel better?  And then I had my “a-ha” moment!  I shouldn’t be resenting him for telling me what I already know – I should be using what I already know.  I had been totally lacking in self-perspective and had my defenses up so high I didn’t want to hear my own good advice. 

I’m not saying any of this to pat myself on the back.  It’s more to record and reaffirm what worked for me, because sometimes I have to work to remember.  There are challenges to being on both the giving and receiving sides of help, especially if you are more used to one than the other. 

Have you ever been a helper who needed to accept help?  Have you been able to use your experiences of being helped to pass along to others?  Leave a note in the comments.

What Inspires Recovery?

This post is a part of the Recovery 101 blog series. The series will explore ideas, philosophies, language, tools and questions about mental health recovery. Submit any ideas for topics in the comments section of any tagged post.


Stories of success in mental health recovery often include a moment of inspiration.  An action by a friend or family member, a life event, a misfortune or a random bit of information learned may act as a catalyst to change in an individual's life.  The stories I have heard often describe a change in the individual's thinking which promotes a drive or motivation to recover.  They reframe their thinking.  They gain hope or a positive outlook.  They create a goal for themselves. 

As workers or support figures we are often searching to find this source of inspiration for our clients or friends.  Doubtless mental illness suffers are seeking it for themselves too.

Last week saw Bell Let's Talk day get lots of attention.  I decided not to write about it at the time due to it being a corporate sponsored event, and I don't have much to say about Bell.  The next day however one of my clients talked about watching a TV interview with Let's Talk spokesperson Clara Hughes along with other famous sports figures talking about their experiences with mental illness (depression and PTSD were covered as far as I remember) and how they recovered.  This client himself suffers with depression.  He told me that watching the show made him feel even worse.  He said they each talked about how their spouse or partner helped them get through - he does not have a spouse, and when he did she was more cause for pain than support.  He said they talked about how despite their various successes (Olympic medals, major trophies and awards) they still suffered.  His take?  If he didn't even have these type of awards, how much worse off does that make him?

Not the intended effect of the program I'm sure.  What was meant to inspire in this case, really didn't help. 

On the other hand I have taken clients to hear recovery stories shared by those in their community and they have reported feeling hopeful in their own lives as a result.  One woman I worked with who has bipolar disorder described watching coverage of Charlie Sheen go off the rails as inspiration for her to get better because she "didn't want to end up like that guy".  There are stories of people going to their doctor, support worker, family member and hearing the same message every day until finally "click!" something registered that was their moment of inspiration.

The moment of inspiration does not result in life getting fixed over night.  Things may not look any different for a while.  But down the road, further along the recovery journey it's the moment that someone looks back on and says "that's when everything changed for me.  That's when I knew I could get better." 

It's the moment that makes all the difference.  Because we can be surrounded by the most well-meaning people in the world, all the praise and validation one could ask for.  But if we are suffering inside, true change will not come until we are open to it.  And the key to open the door may come in all kinds of strange and unpredictable forms.

Language Matters: Non-compliant

This post is a part of the Recovery 101 blog series. The series will explore ideas, philosophies, language, tools, and questions about mental health recovery. Submit any ideas for topics in the comments section of any tagged post.

We in social services know the importance of language. We know that words can hurt or empower. We know that labels may stigmatize. And yet so often our work comes from a place, system or history that promotes these very problems. As one part of the Recovery 101 series I want to explore the language and word that hurt the work we do, as well as the people we work with.


One of my greatest pet peeves is the term “non-compliant”. Direct from the medical and clinic model of treatment, it is usually used to refer to someone who stops taking their medication against medical advice. It may also refer to refusal to participate in other forms of treatment.

When I hear non-compliant I hear:
1) that medication is the sole or primary method of improvement
2) that the treating physician knows what is best
3) that the patient or person is doing something WRONG or even deviant
4) that the patient or person does not have the right to determine how they want to recover
5) the reasons the person has for not taking medications are insignificant compared to what professionals or others perceive as the benefits of the medication
6) the patient or person is sick and must be made better

What alternatives exist to these words:
1) person has decided not to take the prescribed medication
2) person does not find the medication effective, or finds the side-effects unpleasant and is seeking alternative methods
3) the person is comfortable/prefers not taking medications at this time
4) the person has difficulty taking their medications consistently and may need help in this area

How do you view or support clients or others in their decisions around taking medications? Do you use the term non-compliant or have an alternative to suggest? Have you as a patient or person dealing with mental illness felt you have agency or decision making power with regards to medical treatment?

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 Longest Day" or "What am I doing here?"

Note: meant to post this last night, but was too wiped

I am sooo tired today after doing practically nothing.

First thing this morning I went with a client to the Courthouse to attend a free legal clinic. It is one of those places where you take a number then wait. And wait. And wait some more. Three hours later we saw the clerk for about 5 minutes (she was very helpful) before we got out of that place.

5 minutes to eat my lunch (yay! what luck!)

Afternoon spent tracking down the next client (inner monologue: I just saw him just yesterday, and rearranged my schedule to help him out today, wtf is the big idea disappearing now grr), then taking a long drive through traffic to get him to a treatment session at a downtown hospital. That clinic was running late so we waited. And waited. And dozed off….*snork* wha? What happened, where am I? Oh, and waited…I brought a book this time, so at least I was entertained when he finally went in for his appointment. And I waited. And texted my boss to beg her mercy for missing a team meeting I was supposed to be at right that minute. 2.5 hours spent before we left.

Then waded back into traffic for the long slog to get him home. Only to turn around and head right back into it to finally arrive at MY home where I try to reflect on the ways that I helped today.

What a day.

Putting two and two together

Picking up my messages this morning, I had one from a client asking me to help her prepare for a college-entry math test. While I have many skills I feel I can draw upon to support my clients, math is just sooooo not one of them. Trust me honey, let's not even go there!

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.

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.