Sunday, January 31, 2010

Case Manager's Rites of Passage

Waiting in ER with client. Not to be substituted with waiting at social security or public aid office.

Playing phone tag with a provider for over three days.

Tracking down client's public aid (food stamps/medicaid) case worker. Bonus points if client doesn't know case worker's name.

Realizing you can't work harder than your client.

Learning 1 (800) social security number is good for two purposes: 1) Ordering new social security award letter and 2) setting up appointment. Everything else, call the local number. I've received wrong information from representatives at the 1 (800) number.

Client telling you she wants a new case manager / she doesn't want your agency's services anymore (and not as an amicable parting).

Client cries in your office or conversely after she shares her story and leaves your office you cry.

Understanding how much clients teach you.

Friday, January 29, 2010

Client A is in the Lobby, I Can Feel it!

Dear clients, I'm still honing the ability to magically sense you've arrived at our building without you saying a word to our receptionist. I can't say when I'll be able to sharpen this skill. So to be sure I know you've arrived for our appointment, speak up. Sincerely, myself.

Wednesday, January 27, 2010

Dealing with Demanding Clients

Emotionally demanding clients (to case managers) may behave manipulatively, react furiously if their request is denied/otherwise doesn't go as they anticipate it, or constantly walk in and expect to be seen right away. On a different level interacting with clients with mental disorders like obsession or paranoia may be challenging.

It was humbling to read social worker Amy's "I'm sorry they weren't nice to you." I could see a bit of myself in the nurses' response to a tough client who wasn't appreciative of their services, in fact behaved contrarily so. It's demanding to work with other people without getting some positive feedback. Or just get negative feedback. It's touching to hear a thank you or gratitude from a client but also easy to remember vividly the occasional client who tests your patience with an angry or entitled attitude.

On the one hand,
I am doing my job when I work with a client. My compensation is pay. But it's a lie to say that I haven't in the past expected (and thus been disappointed) not to get some form of gratitude or not expected to be treated disrespectfully. It's a part of what I expect in regular human interaction. 

I've also been particularly protective of other staff in the past, especially when clients have cursed and/or screamed at another case manager. It's not part of a professional relationship, it's not the case manager's role to be on the end of a tirade. An attitude of us (ingroup) vs. them (outgroup) may have played a role in this reaction. 

I've seen my agency not take such instances personally and staff try to work issues out with difficult clients from various approaches when the first few don't work. The goal being that if we can help in some way (while staff safety is not undermined) we'll do our best to work with our clients.

Going back to Amy's post. Her words about changing expectations when interacting with clients are very true and encouraged me to see the other side, not just try and understand limitations of empathy from clients with mental illness but limitations that many people may have. It goes along with keeping an emotional distance from clients so not to take negative interaction personally (though somehow only take positive interaction personally). And too, changing expectations when working with clients.

Tuesday, January 26, 2010

So You Didn't Work -- Then How Did you Get By?

You laugh at my question "When was your last job?" and you're 53? You don't have a work history at all? What have you been doing, how have you been surviving? 

I get it, I know there are ways. Working in return for room and board, having partners who pay expenses, illegal activity. But it's such a long time. Is there a study on how people get by without working for over 40 years??

Monday, January 25, 2010

Generic List in Disguise

I like finding humorous online lists. I still occasionally read "Keeping a healthy level of insanity at work" (wish I knew who I could credit authorship) and laugh and laugh.

How excited was I to come across a list of "30 signs you went to (my alma mater)." Universities sometimes have their own slang, humor, or peculiarities. Peculiarities particularly applies to some. I start reading.

Number #2: "[Alma mater students] eat ramen noodle."

Great start. Something no other college student at any other location ever experiences.

Go on to number 3, "[... students] study hard and party hard."

Generic and cliche! Looks like I've fallen on a Barnum list. Applies for virtually any college experience. I loathe these generic, dry lists.

Tuesday, January 19, 2010

Working with Paranoid Clients

I work with a few clients who have paranoid beliefs and typically interactions with them involve a careful balance. On the one hand, I'm not supposed to encourage delusional thoughts and engage ongoing conversations that involve peoples' paranoia. But then how successful is it to tell a person her beliefs are all in her head? Or even discourage her from these thoughts? Even when a person isn't psychotic, her reality is her reality.

A couple of coworkers told me early on to approach clients with paranoid tendencies by saying something along the lines of "This situation must be causing you a lot of stress. Do you have someone to talk to about it?" This would hopefully encourage clients to seek a counselor [we don't have therapists on site]. A therapist would ideally be well equipped to deal with a person with paranoid thoughts.

But then, what to do when a paranoid client already has a psychiatrist and/psychologist. She takes psych medication and still truly believes she's the protagonist in a wide reaching conspiracy. Sometimes I catch myself having a thought of, after hearing the same story again and with such conviction, well who knows? Her reality is so vivid to her. And sometimes these are thoughts people have had for 10, 20, or more years. That alone is hard for me to grasp.

Saturday, January 16, 2010

Here's a List to Help You with that

I skimmed through Nickel and Dimed's play adaptation a few weeks back. One scene, involving Ehrenreich's interaction with a social worker stood out. The social worker, somewhat cheerfully, produces several lists in response to Ehrenreich's queries of where she can get assistance.

It was a little humbling and a little annoying to read. Lists are part of the referral process. Clients ask about a place to get food, find a doctor, subsidized housing options and the like. Lists (and maps) are produced in return. I try to go over information with clients but can understand how they could be overwhelming, i.e. because of cognitive issues or not being familiar with other neighborhoods.

It was annoying to read the scene and recognize it as a cynical take of what social workers do. But it was also humbling in the sense of getting a glimpse of what the other side sees, the person who's coming for help, who is hungry or desperate. It made me appreciate more the need to take time and process through information.

Also see Comments on Nickel and Dimed

Tuesday, January 12, 2010

Magic of Pop

I overheard a participant in a neighboring food program comment to another that the food wasn't so good tonight. The second woman answered, I don't go for the food, I go for the coca cola.

I was somewhat primed to hear this comment. A couple of weeks ago a client told me he goes to the food program (aka soup kitchen) for the pop. Now, I've volunteered in the same soup kitchen on a few occasions and had the food each time. I've enjoyed it. It's a similar menu from month to month, main dishes usually include meat, and meals are fairly healthy but flavorful. 

These incidents (another recent one took place where I overheard a similar comment) got me thinking about the allure of pop. Now I do enjoy my soda drinks. I certainly appreciate another person's enjoyment of them. I also know I would be blowing it out of proportion to think about this too much, but it had already been the third time I heard a client comment about going to the cafe for the drinks. And while maybe the woman was joking about coming to eat for coca cola, the other two weren't. What's this great appeal? It's one thing if a person is experiencing homelessness and say access to drinks are much more difficult. Two clients aren't homeless and should be able to afford a big bottle of soda. Is it that it's free and they can have a lot of it during the meal? Is it the comfort in reliable flavor? Do they really not enjoy the food so much?

Of course a lot of people eat at the food program and I'm putting a lot of weight to three comments. Maybe it was just a coincidence I heard all three in close timing to one another. I suppose the idea that a person would enjoy the drinks more than the food -- to the point it would be deciding factor in bringing them back -- is hard for me to understand (unless a person really has difficult access to soda).

Sunday, January 10, 2010

It's the Principle!

So you, my client, have a neighbor you don't want to deal with. Or his guests. You were on good terms with him until a couple of months ago. Then he stopped being watchful of keeping his music level down and people started coming in and out of his apartment constantly. You talked with him and it didn't help. After bringing it up to management, Mr. landlord offers you to move to another apartment.

Your first response is, "Why should I move when I'm not the problem?" A fair first thought. But if you don't move you still have a problem. In the shape of a bothersome neighbor. And you can tell me you don't think about this neighbor. But somehow all conversations lead back to him.

To myself I admit (and to my client up to a certain point), I get what my client is saying. I'd probably have the same stubborn attitude. If I'm not doing something disruptive -- and in this case I tend to believe my client is telling the truth -- I shouldn't be the one to move. Go through all the hassle. But if thinking about it causes this stress at a certain point it's not worth it. I hope I'd be able to recognize that if I were in a similar situation. I think I would. Eventually. Some things are stronger than doing something on principle.

Saturday, January 9, 2010

Not Ideal, But Maybe Best

A couple of months after I started working at the agency I helped move Jane, a client who had been working intensively with Cara, another case manager. Due to a car accident that took place 5 years ago, Jane suffers from brain damage that affects her memory and comprehension. Cara coordinated a good part of the move, calling the movers, landlord, etc on Jane's behalf.

I still remember the day of the move, looking at Jane pace back and forth, looking around her in disbelief. Jane and Cara had discussed the move and logistics such as where Jane's belongings would go in her new apartment. But the day of it seemed overwhelming for Jane. It was her first move in 20 years.

A few months later Cara left and I started working with Jane. A few weeks ago we learned she was found in lease violation and will need to move. For confidentiality reasons I won't go into details but if my agency had been notified in advance of what was going on we would have had more time to deal with the situation and may have been able to address it. [Although Jane had moved to a new apartment it was still under the same management company.] By the time we were contacted management was fairly adamant it wanted Jane to leave.

The idea of moving her again sounds incredibly overwhelming. To her and staff. The packing, organizing, not to mention finding another place to live. Jane expressed she wants to move to a building that has more support and I agree that it would be best for her. She lived independently for years after her accident but it no longer seems enough. Her having access to case managers on site would give more intensive support I can't give. In fact, the more I think about it I think that setting, compared to living independently, would help her flourish and give her not only a supportive outlet, but social one.

Still, a part of me dreads the move and feels a lot of pressure to find her a new home with little time to work with. Management agreed to let Jane stay for the remaining of her lease but that still doesn't leave a lot of time and usully supportive living facilities have lengthy waiting lists. The way this is happening is particularly traumatic and abrupt for Jane as well. Yes the goal is that she end up in a more nurturing and caring environment and where she is now is not supportive enough, but the process is going to be very difficult.

Tuesday, January 5, 2010

Something for Me to Work on

I was on an elevator with two clients the other day when the it started making creaking noises and shook a little before stopping. "Oh no, keep moving, keep moving, I don't want to get stuck in here," I thought and tapped on the wall of the elevator haphazardly. In a few seconds the elevator creaked into action again. All this time the two clients carried on small talk and laughed about the noise.

Granted, I don't feel comfortable in small, closed spaces that I can't easily get out of but I still admonished myself later for nearly losing my cool. It wasn't pleasant.

Monday, January 4, 2010

Pacing -- The Underappreciated Sport

As gathered from my There's a Sport for Everyone post athletic life and I are usually on distant terms despite my good intentions.

A gentleman opened my eyes to a very simple activity. While I'm waiting for the bus -- in chilly weather -- he suggested that instead of standing I try to pace. That way I would get exercise and stay warm. He then told me he does it himself. "Don't people look at you funny?" I asked him. "Sure, but each bus stop it's different people."

What can I say. I will likely not be joining the gym, I won't be spending more than absolutely necessary walking around, but I will be waiting for the bus. I gave it a try and naturally after a pace or two my coworker asked me what I was doing. When I explained she laughed and said that's a good idea.

This may be a beginning of a movement.