Focus on the good

As a case worker, wherever the road takes us, we go. People come in with all kinds of needs. Some need a job and/or housing, in addition to getting help for their substance issues or mental illness. Others just need to maintain where they’re at in life. For some clients, picking up their medication every week and taking it every day is as high functioning as they will ever be.

When work gets overwhelming, I take my mind off it by exercising or watching TV at night.

I don’t see many big successes, but I do see a lot of small triumphs. The world is filled with a lot of bad things, but you have to focus on the good ones.



Why social work?

Growing up, I was a big fan of the TV show “Judging Amy.” The mother in that show was a case worker. That’s when I first learned what a case worker did. I was interested in it, though in college I majored in psychology, religious studies and theology, with a focus in grief counseling.

In my first job out of college, I was a case manager for people with HIV/AIDS. The people I worked with had a spectrum of problems, including mental illness, drug abuse and homelessness. As a result, the transition to Recovery Resources wasn’t too difficult.

My favorite part of the job is interacting with the clients and hearing their stories. A lot of people don’t have the opportunities I did. Society forgets that they’re people, too. I truly believe that if society was different, we wouldn’t need case managers.

How my time is spent

Every month, 55 percent of my time must be spent in direct service to clients in order to reach the “productivity” goal. It ends up being about 88 hours. I’ve met it every month so far!

The other part of our time is ideally allocated as follows:
Documentation, 25%
Travel, 15%
Administration, 2%
Consultation/Supervision, 2%
Training, 1%

A little bit of this, a little bit of that

I had to tell my clients who are switching levels of care who their new case manager will be. Some of them were upset since we had gotten to know each other.

Other than that, the day was normal. I had a lot of no-shows. I did a home visit with a client who uses the para-transit system and took him to the food bank. I also did a home visit with a client whose mother just died. I wanted to see how she’s doing.

One of my clients has to go before a judge. He is a sex offender who didn’t properly register. If he is found guilty of hiding his address, he could serve between two and eight years.

...yup, just another day at work.

Changing levels of care

I went apartment hunting with Paul a while ago. It went well and we found him a nice 1-bedroom efficiency across from a hospital. He liked it but wanted to see other places. He’ll have to apply, but he wouldn’t sign his name for anything because he’s paranoid. In the car, after looking at a couple of places, he talked it over with himself. It’s interesting and frustrating.

Because he utilizes so much time, Paul will be moved up to a higher level of care. Recovery Resources divides levels of care in four ways. My clients are supposed to be level 1 or 2, meaning they are a bit higher functioning, and I only need to see them once or twice a month. Clients like Paul and Joshua are really closer to level 3 or 4, with more significant needs. The agency is re-arranging case loads to more accurately reflect clients’ needs. Including those two, 28 of my clients are moving to a different level of care. They’re mostly the ones I’ve gotten to know very well, since they’re the ones I see all the time. But now, I’ll be able to see more of my clients.

Helping the way I know best

The only identification that one of my clients has is a court-ordered community service document. The doctor says he’s fit to work, so he can’t get Social Security. But he can’t get a job without a birth certificate, and he has no money to get a birth certificate. It’s a vicious cycle. I wish I could just give him $25 for the birth certificate, but I can’t, because then I’d have to give all my clients $25.

All I can do is help him the way I know best. I helped him apply for food stamps and he got them! I celebrate the small victories...that’s what keeps me going.

Documentation

A large part of my job is documenting my encounters with clients. There is a set format we have to follow for our notes:

1. Summary of Individual Service Plan (ISP)/Individual Service Treatment (IST)

Discuss goals, objectives ordered and objectives addressed

i.e. If a goal is “search for housing,” I might say that at our meeting today, I helped the client figure out what percentage of his income would be spent on rent each month and linked him to an organization that helps find housing.

2. Provide therapeutic intervention

i.e. Ask client, “How’s the housing search going?”

3. Client response

Quote them, if possible. Include any clinically significant events. Are they compliant with their medications?

4. Justify the need for follow up

Include progress/lack of

5. Plan follow-up

What we’re going to do next session. Include recommendations for modifying the treatment plan.

6. Date of last/next psychiatrist visit

Recovery Resources’ CPSTs write notes concurrently with the appointment. I have my laptop out and will type sometimes while the client is talking but I try not to do it too much to detract from his or her attention. If I don’t have a chance to write notes concurrently, I do it right after the session.

Notes can take up to 15 minutes depending on the content of the session. Sessions are typically between 30 and 60 minutes long. Phone calls are billable (and thus note-worthy) after seven minutes. If someone talks longer than three minutes, they’ll usually talk for seven.

Celebrate the little victories

As I mentioned earlier, after I dropped William off at his assessment, I met another client at Jobs and Family Services to help him apply for Medicare. He was thousands of dollars in debt from medical bills. He had Part A Medicare, which covers medical care, but not Part B, which covers doctors. For a while, he was in and out of the hospital every couple weeks for depression. His stay was covered by Part A Medicare, but every time a doctor came to see him, he was slammed with another bill.

At the service center, we were able to get him Part B. He also qualified for the Qualified Medicare Beneficiaries (QMB) program, which is for people who receive Part A Medicare and whose income is 100% below the poverty line. The state will pay the premiums for services covered by Medicare. He also qualified for food stamps.

I’m so happy. The little victories really do help.

High as a kite

A couple weeks later, I went to visit William at the housing complex. (He hadn’t moved out after all.) He seemed like a different person. He was calm and answered my questions. He even agreed to let me take him to our office to get an assessment after I promised him a bus ticket home. I was pleasantly surprised by his demeanor. I checked him in at Recovery Resources then was off to Jobs and Family Services to help another client apply for Medicare.

Later that afternoon, when I returned to the office, my supervisor told me she received a call from the assessment department about William. They were unable to complete the assessment because he was “high as a kite.” I was in shock.

As I said before, you never know what the day will bring.

"I'd rather sleep on the street."

I haven’t met all of my clients. I know most of them, but there are some that I have yet to talk to for various reasons.

A couple months ago, I got a call from a housing manager saying that one of her clients, William,* needed case worker services. He hadn’t been acting himself lately and missed a month of rent. William was one of these clients I had never met. I inherited him from the case worker before me.

Arriving at the housing unit, I met the manager who filled me in on her history with William. He had always been a good tenant and paid rent on time until recently. When I finally got the chance to talk to William, he was irritable. He was mad at himself for spending all of his money on cocaine and alcohol, then got mad at me when I suggested a solution. The housing manager and I agreed a payee—a third-party handler of his money—arrangement would be best. William’s Social Security check would be sent to the payee, usually a bank, who would write a check for William’s rent before depositing the remaining money in his account. However, William was adamantly opposed to this idea and insisted on having full control of his money. I tried to persuade him, but was unsuccessful.

He then decided that he didn’t even want to live there anymore. “I just want to leave,” he said. The housing manager and I tried to tell him that even if he left now, he’d still be responsible for the missed rent, as well as incur a fine for breaking the lease without proper warning.  He didn’t seem to comprehend the situation and instead began insisting that he would rather sleep on the street than live in this complex. It was obvious that something was up. Was he under the influence now, as we were talking to him?

Nobody in his right mind chooses homelessness, I thought.

Constant evaluation

When I was with Paul, and when I’m with any of my clients, I’m constantly evaluating their responses and behaviors. If they’re acting a little off, I want to figure out why. Is there a relationships issue with a family, friend or significant other? Have they been sleeping well? Did they not take their medication? Did they start using alcohol or drugs again? Round and round in my head their answers go, as I try to make sense of all of it.

Their answers, and the solutions, are as varied as the clients.

"You're not listening!"

One day, my two morning appointments canceled and then Paul,* one of my afternoon appointments, called.

“I don’t have any food, and I don’t have any money to come to the appointment,” he said, so I decided to pay him a home visit. I wanted to take him food, too, so I tried to research food pantries near his house. I finally found one he was eligible for. The people at the pantry were nice enough to let me get food for Paul after I gave them all his information to ensure he wouldn’t double dip later in the month.

Paul’s apartment building was difficult to find but I finally located it. “Sorry it’s disordered,” Paul says as he opens the door to his apartment. “It’s how I’m feeling right now.”

After he thanked me for the food and put it away, we went outside. The fire escape was the only place to sit. He sat down and I sat on the ground. Paul pulled out a long white cigarette, lit it and began talking.

After filling me in about his week, Paul drifted to another world and his disease started talking. “I can see the stage, I can see the performers on the stage, but I can also see what’s behind the curtain…Do you know what I discovered? Humans have the ability to have their eyes open to many different worlds at once.”

I ask him about his next Dr.’s appointment and ask him when he last used drugs. He gets very frustrated. “You’re not listening to me!” he says, then begins to talking to himself.I am listening to him, though. I hear him say that he wants to get his life back together and go back to school. I’m trying to help him achieve his goals. He seems worse than last week, and I’m trying to figure out if it’s because he’s using substances again. I want to help. That’s why I became a case worker.

Everything will be ok

Another one of my clients had her kids taken from her by the court. Since then, she’s been compliant with medications and meetings, so I wrote a letter to the judge telling him what I knew and faxed it to her lawyer. The lawyer gave me all the information about her next court date. She is worried that she won’t get her kids back, but I tell her everything will be okay. She’s not being charged with abuse or neglect, just issues of dependence. It’s through no fault of hers that her kids were taken away. It’s because of her mental illness.

You can't fix the world

One of my clients tried to commit suicide. He’s a family man and is upset he can’t support his family. He’s been out of work for four years. He was down on himself because he couldn’t buy anything for his son’s birthday. Luckily we were able to stop him in time.

As a case worker, you learn you can only help your clients so much. You can’t fix the world, but you can help some people in a small way.

No such thing as a "normal day"

I have about 60 clients. At times it has been as many as 135, but even with 60, it’s hectic. I see clients both at the office and in their homes. It's always a game, trying to figure out who will and won't show up for their appointments. Most afternoons, I’m out in the community, paying home visits and getting clients the help they need. I never know what the day will bring.

 

The "Bible" of mental disorders

There are pages of resources all over my office. I have a list of welfare offices, food programs, gambling addiction services, low cost dentists, landlords who accept sex offenders, etc. It’s everything my clients have needed in the past and will probably find useful in the future.

One important resource I use is the Diagnostic and Statistical Manual of Mental Disorders, otherwise known as the DSM. It’s a classification system of mental disorders. Psychiatric diagnoses are organized into five levels, or axes. The axes are as follows:

• Axis I: Clinical disorders
• e.g. depression, anxiety, anorexia, ADHD, autism
• Axis II: Personality disorders and mental retardation
• e.g. obsessive-compulsive personality disorder, borderline personality disorder
• Axis III: General medical conditions
• e.g. heart condition, diabetes
• Axis IV: Psychosocial and environmental problems
• housing, education, economic problems
• Axis V: Global Assessment of Functioning (GAF)
• 0-100 scale rating the psychological, social and occupational functioning of adults

(from DSM-IV-TR)

Even though I don’t diagnose the clients, understanding their diagnosis is important to understanding them. My patients’ most common diagnoses are on Axes I and II: schizophrenia, bipolar and depression.

Getting to know the client

When I meet a new client, the first thing I do is gather background information. Some clients come in and know exactly what they want, be it a job, housing or mental stability. Others don’t say much. Some clients don’t want to trust me because they haven’t been able to trust anyone in their life. It’s a give and take.
I ask them questions about their strengths, weaknesses, hopes and wishes. I also try to learn as much as possible about their disease.

Questions I might ask:
What do you hope to accomplish through treatment?
What are your symptoms?
If you take medications, what do you take and how do you take them? (Some people take them all at once...not good!)
Are there any side effects to your medication?
Do you have medical insurance or a source of income? (If they don’t have insurance, one of the first things I do is try to sign them up for Medicare)
Do you have a criminal history?

The more I know, the more effectively I can help them.

What is a CPST?

My official job title is Community Psychiatric Supportive Treatment Specialist (CPST). The short description of my position is: “Works with clients to implement a comprehensive treatment plan that addresses their daily living needs and helps them maintain psychiatric stability and sobriety.”

Responsibilities include empowering clients to make life decisions, providing clients with services at various locations and responding in a timely manner to situations that might destabilize the client. I also have to complete accurate and timely documentation and reports (more details later).

The most important qualities a CPST should possess are compassion, sensitivity, patience, the desire to make a difference and the ability to relate well to all kinds of people. A B.A. in Social Work or a related field is required and an LSW (Licensed Social Worker) or PC (Professional Counselor) or equivalent is preferred.

The rewards and challenges of being a CPST

First step to treatment

The first step to getting treatment at Recovery Resources is an integrated assessment. An assessment is a confidential consultation between a licensed mental health professional and a potential client that is used to diagnose clients and develop an appropriate course of treatment. If the assessor determines that case management services are needed for treatment, the client meets with a Clinical Care Coordinator (my supervisor) to develop a treatment plan. The treatment plan includes the client’s diagnosis information, strengths, needs, goals, objectives and planned services. With my clients, the goal is typically “to obtain and maintain psychiatric stability and understand how symptoms of mental illness and addiction impact each other.”

A client's needs might include any combination of the following: the abuse of substances, unstable mental health status, lack of income and inadequate housing. An objective is developed for each need. For example, for someone abusing substances, the objective may be for the client to learn how to identify the thoughts and behaviors that lead to substance use and then how to practice the behaviors that prevent relapse.

My job as the case manager is to help clients achieve their goals by meeting their objectives and, ultimately, their needs.

Hi, my name is Brianne

Hi, my name is Brianne and I’m a case worker for Recovery Resources in Cleveland, Ohio. I love my job and enjoy interacting with my clients. Most of my clients are dually diagnosed with substance abuse and mental health issues. As you can imagine, there is never a boring day at the office!

This blog will give you an inside look at the life of a case worker—the unpredictable clients, the never ending “paper trail” of forms and the small yet immensely rewarding client victories. The blog will be updated regularly, so be sure to bookmark it and come back often.

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