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.


Anxiety Avalanche!

This past few weeks I have felt like I have been on a crash course on anxiety. Not personally but through my work I have facilitated a group on Anxiety, and was handed clients with an array of anxiety disorders including Generalized Anxiety Disorder, Panic attacks, Obsessive compulsive disorder, and post-traumatic stress disorder. 

We all can relate to experiencing anxiety in our lives.  I only recently wrote about feeling anxiety in regard to interviews I had gone through.  In this regard, experiencing a feeling of anxiety is a normal part of our stress response that enables us to respond to life’s challenging situations.  For example, a woman that is assaulted by a particular man may wisely flee the scene when he comes toward her again. 

Increased heart rate, sweating, and other symptoms of anxiety prepare us for these flight or fight responses that have helped us through the ages in survival.  Now we get these same responses in our everyday technologically oriented lives in response to anticipated event, but also in response to thoughts and feelings about these events.

Those with anxiety disorders are characterized by avoidance anticipatory fear- or more simply fear of experiencing an event or a feeling that has not happened (yet).  

Instead of accepting or experiencing fears or unpleasant emotions with an anticipatory event will use methods to avoid these events and control their emotions or thoughts, but unfortunately these only exacerbate anxiety symptoms. 

A funny example told in the book I am currently reading on Acceptance and Commitment therapy for anxiety disorders tells the story of how one woman after an accident would try to avoid to take left turns due to having been in an accident where she was taking a left turn.  You can imagine how much time and inconvenience it would add to her life and how this increasingly complicated route could cause even more stress in her life as she increasingly revisits her fear of left turns in avoiding them in turn also strengthening her anxiety.

There is a strong physiological component in anxiety, in addition to the usual mix of thoughts, feelings and behaviors that contribute to the cycle of anxiety. Anxiety can result in panic attacks which can be mistaken as a heart attack, headaches, and other bodily symptoms. As a result anxiety sufferers may spend a lot of time trying to figure out what is going wrong with them before they consider anxiety as a possible culprit.

One unanswered question about anxiety is why some people go on to develop anxiety disorders and others do not.  For example, the majority of people who experience traumatic events do not develop long term PTSD.  We know what makes someone’s anxiety response disordered or problematic but that does not help us with what is behind an anxiety disorder.

In this book Acceptance and Commitment Therapy for Anxiety disorders (Eisert and Forsyth, 2005) they believe that what makes anxiety disordered is a rigid control and non-acceptance.  This is most obvious is obsessive-compulsive disorder where a person usually realizes that their actions are irrational and can easily identify alternative action or thoughts but is unable to accept a lack of certainty (“I may have not checked the lock, I better go back, even thought I likely did”).  They propose that simply helping someone be better at controlling their emotional regulation and thoughts will not be adequate to help those with anxiety disorders as anxiety sufferers already interpret these negative emotional states as “bad” and needing to be managed and controlled at all costs. They acknowledge that it is important to confront fears by not avoiding, but also recognize that it is important to learn to live with anxiety, rather than flee the actual emotional state.

So that’s my crash course on understanding anxiety in a nutshell!  Now how to deal with it in therapy- another post altogether!


Prayers for helping professionals: St. Theresa of Avila’s “Let Nothing Disturb Thee”

Many years ago I came across this prayer by St. Theresa of Avila, a mystic and nun of the 16th century.

Let nothing disturb thee

Nothing affright thee

All things are passing

God never changeth

Patient endurance

Attaineth to all things

Who God possesseth

In nothing is wanting

Alone God sufficeth

I have recited this prayer in times of stress and anxiety during my life. Let nothing disturb thee herald’s back to countless biblical passages where God’s people are exhorted to fear God, not men ( eg Psalm 56:4: God, whose word I praise, in God I trust; I will not be afraid. What can mortal man do to me?). 

As a social worker working with people experiencing profound mental confusion, crises, and chaos in their lives it is essential to have a firm anchor in God.  Especially when it seems like even the best therapies fail, medications only provide minimal relief, and support is refused.  Ultimately, God is present and I will trust and pray for him to be with this client and myself in this mess we call life.  

It seems so simple, just trust in God, He never changes He’s always there. But we are afraid, we are disturbed by what we see. That is why we get into the work we do- because the state of the world disturbs us and we want to do something about it. 

And it seems at first glance that this prayer provides no recourse, no action to take about that which disturbs us.  Are we left retreat to our personal prayer with God away from these disturbances or claim that these disturbances are perceptions of reality that create suffering (a more Buddhist viewpoint)?

I think this prayer could be interpreted this way but one line challenges me toward engagement: “Patient endurance attaineth all things”.  Patient endurance is an active choice, not a passive observer stance.  It’s like seeing a rushing river that you need to cross and instead of sitting on one side and fretting about it to instead decide to get in up to your waist in rushing water, hold on to whatever you can to get you across and endure the cold water as long as you have to until you reach the other side. 

This is what our life is like, but to patiently endure we must be “possessed” by God.  When we think of the word possessed we often have images of demon possession and exorcism by Catholic priests.  Very rarely do we hear of being possessed by God. Being possessed implies being owned or filled in its entirety. In being possessed by God Saint Theresa rightly says that nothing is wanting.  There is no need if God lives fully in us and through us.

As a social worker this is not easily done.  My place of work, like many of you, does not have its sole purpose in serving and loving God but is there to control and fix situations.  Very rarely can we offer people God’s solace and grace as a salve to their problems.  Mostly we can offer the accepted wisdom of our profession. 

This makes it difficult to be wholly possessed by God.  Maybe St. Theresa had it right in setting up convents and encouraging people to pray and seek God after all. 

How do you manage to keep centred and “possessed” by God as you engage in a secular helping system?