Welcome to the first in my new periodic series here at The Social Work Practitioner called Once Upon A Client. Once Upon A Client will explore aspects of social work practice through experiences I’ve had with particular clients. These experiences will speak directly to abilities and skill sets that are essential for us as social workers to develop. Names, of course, are always changed and circumstances sufficiently muddied so as to maintain confidentiality.
Once upon a client, there was Raymond.
Raymond arrived 45 minutes late for a scheduled one-hour intake. He was toting a large green canvas bag, stained and torn, the size of an overstuffed backpack. “Ray-Ray” hoisted it onto my desk with a thud as he undid the clasp and proceeded to turn it upside down. The papers were log jammed at first, but with a couple of surprisingly vigorous shakes for so slight a man, they began to plop and slide out. As he lifted the bag higher and higher and shook, the tumbling out continued. Papers after papers, stapled, clipped, and rubber-banded, sliding off two sides of my desk onto the floor and consuming my keyboard like a tsunami. I lifted my coffee out of danger in the nick of time, too stunned to say anything but “Well, don’t you have a lot of papers there!” eyes wide and eyebrows raised. When done he ceremoniously dropped the emptied bag, which dragged a bunch of papers with it onto the floor and said, “I need some help here.”
“Looks like you do” was all I could eek out, befuddled and grinning like an idiot. Truth is, I was overwhelmed. My heart was thumping, I became instantly light-headed, and I didn’t know what else to say.
I had stood up to shake his hand when he entered my cubicle, but slowly sat back down. Then, before another thought had a chance to slip into my brain sideways, Raymond flashed some more of his history—literally. Lifting his shirt fully to his armpits, he revealed a twelve-inch scar from just above his navel to a few inches below his collarbone. I was horrified, and lost.
At this point, what would you have done?
1) Let him know that before the two of you could talk he needed to pick up all his papers (of course you’d help)
2) Excused yourself to get your supervisor
3) Cried / laughed / run out screaming
4) Told him that because he was late and would need time to pick up his papers (again, you’d help) that you would have to reschedule
5) Nothing (i.e., continued with the meeting)
I did number five. Newbie mistake.
I was a first year MSW intern at Coalition for the Homeless in New York City, learning intensive case management in the Client Advocacy Program (CAP). The CAP’s goals were two-fold: to help disabled street homeless and shelter residents obtain Social Security disability benefits, and to leverage those benefits into a move off the streets or out of shelter and into supportive housing. It was very early on and I was meeting clients for the first time, assessing them to see if the program was appropriate for the kind of help they needed. Ray-Ray had been referred from the Coalition’s Crisis Intervention program as someone who might be psychiatrically disabled to the extent that he might qualify for federal benefits.
Well, at that point I didn’t know if Raymond was psychiatrically disabled or not, but for the whole time I sat there I felt functionally disabled. He was forceful, a little scary, extremely bright, and he’d just dumped his world of problems all over my desk. I was so flooded with “What the…?” that I did not ask him to sit down. I did not offer him a drink of water. I did not talk about my program. I’m not even sure I introduced myself. I sat back checking my breathing, gripping the arm rests of my chair and let him talk and pace and talk and pace. I didn’t know what to do, and didn’t ask for help. To make it worse, my next client was on time and I kept her waiting for over a half hour. Not okay.
Let’s have a look at a clip from the “20/20 hindsight” reel. Here’s what I wish I’d done.
1) Meet him where he’s at. Raymond came in energetically and very focused on his agenda. I needed to meet him with the same presence and strength. When he started to dump his bag, I needed to make some effort to stop him. Calmly, clearly, but matching his energy I needed to say “Mr. Raymond, hold on for a moment please? Before you empty your bag we’re a little short on time, so let’s cover a few bases first.”
2) Engage in appropriate social niceties. Introduced myself. Offered a chair, a drink of water. All those things I was too stunned to remember.
3) Manage the time. I should have acknowledged that there is only 15 minutes remaining before the next appointment, and that I understand things happen that can sometimes make us late. I’d let him know that I will always do my best to respect his time by working hard to finish the session before his on time, so that he should not have to wait to see me. That being the case, I did not want to keep the next client waiting. Since I am very interested in hearing what he has to say and given the amount of material we need to cover, the first thing we should do is schedule the next appointment. “Then I’d like to hear what brings you to our program today and briefly share some information about the Client Advocacy Program in the time we have remaining.”
4) Check in. “How are you doing, Mr. Raymond?” Try to keep his response focused in the present. Oh, it’ll be a challenge—after all, he just dumped a big chunk of his life on the desk. The client, depending on who they are and what challenges they are living with, can take the “How are you?” question and run with it and start to get into history you don’t have time to unpack. If that were the case I’d need to step in respectfully, but firmly, and let him know that I want to be sure he has certain important information to think about in anticipation of our next meeting, when we’d have time to go into fuller detail about what’s going on in his life.
5) Set the agenda for the next meeting. I needed to try and provide the information I’d just referred to, including any handouts or other materials he may find helpful. Give him my card with the day, date, and appointment time on it. Make sure he understands what’s written there (in case there is a vision or literacy problem). If there’s any time left, talk a little. All this could have been done while helping him clean up his papers—after asking him first. Some folks don’t want you touching their stuff.
6) Close the meeting. Don’t assume the meeting will end neatly. “Thank you.” “Thanks.” “Nice meeting you.” “Bye.” Uh-uh. If it does, great, but many times it won’t, particularly if you’re working in mental health with someone who is floridly symptomatic. If the client is still talking, you can always say as you walk out of your cube area or office “Please, come walk with me while we’re chatting.” If you have a client who’s hell-bent on continuing the conversation and you are not stopping them from talking, odds are they will walk with you. Continue your focused attention and active listening as you head toward the elevator or building exit, being mindful of confidentiality issues and reminding them, if necessary, that their business is their business and that there are other folks around.
Like I said, 20/20 hindsight.
On this last point, I have often walked a client to the elevator, pushed the button, and continued chatting until it came. If they stopped engaging I would at times simply thank them, turn around, and go back to my cube. Otherwise I would wait until they boarded with a “See you next Tuesday morning at 10” or some such. The important thing is to remain respectful and engaged so they don’t feel like you’re rushing them out, but rather reinforcing that their time with you will be similarly respected.
Setting and maintaining boundaries is a huge topic and could be the subject of its own blog. This brief exploration highlights the importance of setting the proper tone from the beginning so the client feels informed, respected, you feel grounded, and work can proceed as it should.
NEXT WEEK: Supervision – A Meeting of the Minds
Question for Further Consideration
1) What alternative strategies might you have employed to handle Ray-Ray’s assertiveness?
Perhaps 1, however given what Raymond did he may not be aware of boundries, etc. he could’ve been suffering from a mental disorder, then what? The mess definitely, had to be dealt with, but more importantly the client needs, (client centered care). The approach could’ve been motivational interveiwing, MI, engaging Raymond first on what brings him to you, then based on what the response is proceed from there. Oftentime what we learn in social work is a “clinical approach” and while that is needed and important we sometimes forget to apply basic skills that gets a client like Raymond or any other client with a mental disorder to be part of a process. Which is going to help him and get him from A to B, and this will allow us to know the level of care client needs, placement and/or referral.
I agree, regarding the motivational interviewing piece, which I alluded to in Item 3 (“Manage the time”).
Thank you for reading and writing!
I would have guessed you would did option number 1. It seemed like the perfect way to redirect the situation to the point at hand and be able to see your desk again. Of course, I did not think about how he would have reacted to picking up their papers without their permission. I like your pointers, great advice.
Thanks for giving me a read and taking the time to comment.
Option 1 stated “Let him know that before the two of you could talk he needed to pick up all his papers (of course you’d help).” What I wished I’d done was listed in the subsequent numbers 1-6 (next time I won’t repeat the same numbering scheme in the same posting).
Here’s the thing: we need to set boundaries when our own boundaries are being disrespected OR, as in this case, the clients themselves are not demonstrating an understanding of appropriate boundaries. Often, those go hand-in-hand.
Option 1 certainly is… an option! I would not choose it, however, because it sets up a power struggle that is not necessary in order to move things forward and could, in fact, create a secondary obstacle to engagement (the first being the client’s lack of an appropriate boundary when coming into the professional space of someone who they want help from). Taking the stance on Option 1 says, in effect, “I will not talk to you unless you clean up your mess.” It’s parental, reminding the client “who’s boss” (and what’s that about?)—I do not see this as helpful. Particularly for clients who live for conflict (everything is the subject of an argument), such a stance just gives them something to push back against. Then what?
Hope this addresses the point you raised. If not, let me know and I will try again.