From therapy to case management

In my new job I’ve switched from doing therapy with people 100% of the time do now doing 80% case management and about 20% therapy in my new role working with adults with chronic mental illnesses mostly those with psychosis of some sort, and also those with bipolar or longstanding and complex mental illness of varying sorts.

Some would call it a fall from grace other people would call it a chance to directly impact people’s lives.

The work I do now puts me squarely in the medical model as I work closely with the psychiatrists monitoring medication adherence and tolerance, as well as working together with the client on a movement to recovery in their mental illness. 

One positive aspect of my job is now working more closely with Occupational Therapists at our centre who do a wonderful job of connecting people with activities, socialization and even housing.  The job of the OT and case manager overlaps at times as I may be actively working on some areas that OT’s may also help with (housing for example).  The OT’s run groups at some of the community mental health clubhouses and by doing this they introduce the clients to a new community support network.

Because of the short-term nature of my previous job doing therapy I did not usually refer my clients to these resources as they were not appropriate supports, or the person was independent enough to connect individually.

I miss doing therapy greatly.  I have a number of clients I have offered to do therapy.  For example, one client with schizophrenia (now under control with meds) and OCD.  We will be working on the OCD together in therapy.  This will be a new challenge for me as I have not worked with someone on OCD before and because of his also having a diagnosis of schizophrenia. 

Working in therapy on this team is generally harder for a couple of reasons.  Firstly my caseload is at least double and almost triple what it was before- so I am caring for more people with the same amount of time in a week- so in this model I cannot do therapy with everyone but with somewhere between 5-12 people at a time.

People come to our team because they have had a mental illness for some time; this can make therapy harder as they and those around them have accepted that this is how life is for them.  Therapy can feel threatening as if to challenge the equilibrium they may have found.  Most people have had case management for a long time (usually meeting once a month for a 1/2 hour) that they are accustomed to the care they have. 

Other people benefit so much from medications and are well-supported by family and involved  in their community (many of my clients are christians who go to church regularly) that the focus is much different; on relapse-prevention planning and re-enforcing and maintaining good support.

 What I have noticed is that in some people with psychotic disorders there is  a strong anxiety component.  For example, a cleint may  have had hallucinations and delusions in the past but they are now managed by medication but still they have significant fear and worry in their lives, and have difficulty handling difficult emotions, like shame or embarrassment.

These are the folks that I would like to do some basic therapy for anxiety.  However, given their chronic nature and how negatively their mental illness has impacted their ability to function in basic areas of their life they may have a harder time engaging in traditional CBT therapy- some of them are just not interested as well. 

This is the challenge ahead.  I hope there will be some encouragement in undertaking this work with those who are ready and providing support to all of my clients in meeting their goals and needs wherever they are on their road towards greater wellness.

Advertisements

Working in your own neighborhood

Although social work has its roots in community development, and being “with” people, with the strengthening of ethics and the discouragement of “dual relationships” many people find it much easier to work in social work outside their own neighborhood, where there is less likelihood of running into their clients in the choir, at the park, at church, at the grocery store, as their children’s teachers, etc.

This is especially true when a person works in a place of authority (child protection, mental health worker who has to certify people against there will) or of confidence (therapist, counsellor).  In these positions you know a lot about people that other neighbors do not that can make interactions awkward and both client and worker may find it difficult to draw clear boundaries between work and home life.

I was recently interviewed for a position working in mental health kitty corner from my house- visual distance.  I am fairly involved in my neighborhood, helping out at a local dinner at a community house and have folks over regularly to my dinner from church who are clients of that team.  If I took that position I would more than likely see clients at the same dinner table often; this could be difficult in mental health if someone already has paranoia that someone is following them.  I loved the idea of working in the neighborhood but in the end I decided not to and chose to stay working just a 15 minute drive away at the organization I currently at, but in a different department. In the end I chose to keep my role as that of a friend and neighbor only; I want to be able to invite people for coffee without worrying that I am somehow breaking a rule by inadvertently inviting in someone who is already on the mental health team and I may work with in filling in for a colleague. I want to be able to fully participate in the community without drawing my curtains in or relaxing in other parts of the city for fear that if I leave my home I will be actually working at not working.

In some ways I want to break this tendency to want to completely separate work and play as it seems kind of artificial.  It perpetuates differentiation in the class and status of worker and client.  For example, if I was in the neighborhood my clients would see my two year-old having a tantrum on the sidewalk; I would feel a little embarrassed, similarly I might see them in the soup line across the street from my house or working as a prostitute at a nearby street corner.  Perhaps this would make all of us a little more real and humble.  Hard to say.

 

 

Interviewing Anxiety

Last thursday I handed in my final graduating essay to my advisor; with a click of the send button I had finished the last requirement of my MSW degree.

With excitement I called my husband and let him know the good news.  With this newfound freedom I celebrated with a visit to a cafe and more phone calls to my family back home.

The next day while at a massage therapy appointment my cell phone rang; who would be calling me?  I had a few ideas, but relatively few people have my phone number so I was curious.

To my astonishment I got a call for an interview for a casual counsellor position from a local treatment program for women that is unique in providing trauma-informed care to women with multiple barriers.

I had applied to this job with little expectation that I would get an interview; I simply applied because I have long wanted to work with women in addiction using a trauma informed approach.  I do not have particular employment experience specifically with women so I was surprised to get this call.

At first I felt elation then later anxiety.  Anxiety for a number of compounding reasons.  I was worried that I would be stumped by difficult questions.  I was worried as it is coming up within a matter of days without much time to prepare, let alone buy a few new clothes, hair cut.  More than anything I need some new glasses and contact lenses; for the past few months I have been wearing broken glasses taped together with black electrical tape.  I have been so busy being a mom and a student that I haven’t even had time to buy things for “me”!

I was also worried strangely enough because the future was now much more uncertain- with me perhaps having to make difficult choices. It was hinted that I would be interviewed for a casual position in counselling at my mental health practicum that I had applied for two weeks earlier.  I had already set my course on that potential job, excited to see old colleagues when this possibility came up. Now I felt quite anxious not only about a difficult interview but potentially having to choose between this new position and the opportunity to work somewhere that I had grown to feel comfortable and would have the opportunity to  learn more about providing therapy to people with a variety of conditions.

Writing about my anxieties makes them feel trivial- likely I will get a job, the bills will be paid and I will continue to learn and grow in social work/therapy.  However, nonetheless these thoughts have dominated my head over the last day and a half as I have dwelt on the repercussions of one choice or another.

What helped with the anxiety?  Strangely enough not mindfulness but reading: reading about women, substance abuse and trauma brought me a lot of excitement which made me feel encouraged to study and put my best foot forward for this upcoming interview. And now my anxiety is at a record low.  Now just to care of the essentials: hair cut, interview outfit, contact lenses, and interview prep (ok that one still causes me a little bit of anxiety).

So if you were a therapist, what was the technique I used?  What helped me get through this?

In a concluding note: I am extremely grateful and blessed to have made it through this journey through my MSW.  As many of you know, midway through my first year of the program I found out that I was expecting a baby- surprise!  God’s planning, I call it.  I took one year off from studies- missed graduating with my original cohort.  However, God has provided, finances, work, everything I needed, and learning opportunities.  With his strength I have completed the finances and engaged in the learning gradually taking the courage to integrate my faith into my understanding.  It has been a wild journey, not without bumps but I’m glad I’ve made it through this leg of the journey intact (and thriving, and happy- with a healthy dose of anxiety here and there).

Structural Social Work and Clinical Practice

Over the past few weeks I have been absent from blogging because I am in the last month of my masters program, meaning that rightfully I am (trying to) spend more time doing school work than other things like checking e-mail and blogging.

However, I have not ceased entertaining new ideas for posts. 

As those of you who are in the field of social work may know our educational institutions have largely shifted the philosophy of education to that of a philosophy of structural social work.  This means that our level of analysis is to always include the impacts of unjust societal arrangements on people’s problems.  In The Structural Approach to Direct Practice in Social Work (Goldberg Wood and Tully, 2006)  it emphasizes the importance of trying to change an oppressive situation before engaging in clinical work with an individual.   For example, a depressed elderly person fearful to leave the home may need increased protection from police to decrease gang violence or a change of home to a safer neighborhood, not simply therapy to deal with fear.  In this type of example the author explains that it would likely be futile to engage in therapy without first addressing her environment or larger systemic problems contributing to her individual problem.

This seems logical for this particular situation, but for social workers the tools and ability to change a situation of a barrier for a client are out of reach or take too much time to truly benefit an individual.  In seeing the picture we have the burden (my our profession and our education) to change the bigger picture to benefit our clients; few other professions have this within their aims or purposes.

The reality is that many social workers (myself included) choose to practice on and individual level using clinical skills borrowed and developed from the field of psychology.  However, in being a social worker we have the added layer of assessing for the role of social and environment and then working for change within that realm as well as on the individual level.  This is helpful, but also challenging and can go outside of the framework of evidence based practice models that we may be using to mix it with an advocate role.  One complication of using a structural model is that in theory it is quite black and white (fight injustice!), but in practice people and situations are far more complicated; the oppressed are oppressors, we are both holding power and without power, resisting and engaging. 

In some cases in my work I have found it is not very applicable.  For example in counselling a middle-aged women with depression reporting a satisfactory marriage and middle-income status I am building a relationship and targeting symptoms of depression with various counselling techniques; I’m not working on an issues of injustice as she did not bring that forward after careful assessment.

However, at other times the knowledge of the effect of injustice, the barriers faced by those who are discriminated against can be used in therapy to help people normalize their experience and understand that our system is not just a meritocracy and that their not “making it” in life is not just an effect of a character flaw. Looking first to understand who is disadvantaged and discriminated against is also a good guide to research.  For example if I am doing research and find out that those with lower-income consistently die more after having cardiac surgery I would not just accept this fact but want to examine the structures that contribute to this injustice and lobby to change this.

So there are advantages to having a grounding in structural theory, but also limitations in practice.

As a social worker do you use structural theory as a basis for your work?  How well does it go work within the context of your agency/practice?  What alternative models do you find useful?