Complex clients

Many of our clients have complex lives, and experience complex relationships and issues within these lives, and working with these clients can be a challenge for us.

Breaking down the main issues

I have always found it useful, especially in supervision, to separate out the key issues in diagrammatic form, and to include contributing factors to these issues, and then the impact of these issues on each other as we tease them out more.

An example of key issues

The client is a 34 yr old female who has two children (an 8 yr old boy and a 5 yr old girl) and separated from her husband 6 months ago after he had an affair. Her mother, who provided a lot of support, died unexpectedly of a heart attack 1 month ago, and the client was made redundant from her employment as an administration assistant when the company folded 2 weeks ago. She was diagnosed with Type 2 Diabetes a year ago and is currently addicted to cannabis  and regularly binge drinks alcohol. Her addiction history in unclear.

Initially the key issues could be summarised thus:

Adding contributing factors

Once these are added, our diagram may look like this:

Adding connections and impacts

These would be added to the diagram above which includes the contributing factors, but for the sake of simplicity I have deleted the contributing factors from the diagram below:

Making sense of the complexities

Now we can use the diagrams to consider possible hypotheses and additional areas to explore with the client. The history of addiction may not be as important to explore at this stage when the immediate impact of grief and separation is more relevant to address. And with this client it will be vitally important to work on building a relationship of trust with her.

I hope that you find this process as useful as I have.

Mourning the demise of Community Health

On Saturday I attended an open day for the new Hospital/ Health Facility in the town in which I have spent most of my working life as a Community Health Social Worker. It was nice and shiny and full of expensive new equipment, but it was also the reason I chose to retire. Community Health will now be absorbed into Ambulatory Care (and the name will be lost) and Social Workers will be part of the Allied Health team (as they have been more recently), who will have work stations in one large room, rather than offices of their own (which they have had up until now). There is a new emphasis on Integrated Care and I predict that Social Work will become much more medically focused.

Having been a pioneer in Community Health in this town way back in 1976 (there was only myself and a Community Nurse then and our office was initially the kitchen of the Baby Health Rooms in the CWA building), I would like acknowledge some of the history.

The early days

My mother recently sent me letters I had written to her back in the 1970’s and I would like to share some quotes from these letters. Back then Community Health was a new initiative of the Whitlam Government and was Commonwealth funded. I flew out from Sydney, had a chat with the Deputy Regional Manager (referred to as Dr R in the letters), was offered a choice of about 4 towns and, a few months later, found myself picking up a brand new Ford Falcon work car to drive out, having transferred from Liverpool Community Health in Sydney (and having been promised the construction of demountable offices at the rear of the CWA Hall).

6/2/1976

I am now thoroughly exhausted after my first week here… I spent most of the week introducing myself to other people in the welfare field. I mostly got a good reception.

19/2/76

The C of E Archdeacon came up to me and told me a lady from his church would like to talk to me about some girls who are concerning her. I went the next day, but was unable to do much – still it’s another good contact…. Things are now settling down at work and I'm getting some decent cases at last … I’d just like somewhere to work … our modular office has fallen through since the council suddenly decided the CWA Hall is in an all brick zone! … I went out to T. last week and had a really nice day – I get on really well with the Community Nurse there… I'm going to P. tomorrow and I have to leave early (8.30 am.).

25/2/76

Dr R phoned me today to see how I was going – so I told him I’d like somewhere to work and that I wasn't exactly overloaded with work – he suggested I go down and talk things over with him next week, which I thought was nice of him.

14/3/76

The Regional Geriatrician said he had heard that I was very unhappy, and could still transfer to O. if I wanted to. I explained to him that is was my flat trouble that was upsetting me and that I thought it would be very bad for the town in terms of accepting future Social Workers if I just got up and left now. The work situation is now much better – I have a reasonable amount of work to do and am beginning to feel accepted by the community. I was invited to give a talk to the Primary School Mother’s Club on Tuesday… I got through my talk alright, although now I keep thinking of things I should have told them.

3/4/76

Well I can’t complain any more about not having enough work to do – after last week I feel utterly exhausted and seem to have more than I can cope with. I also did a lot of driving, which is exhausting. I went to T. on Tuesday and again on Friday, to C. on Thurs and to a farm out the back of G. also on Tues … We’re still having hassles over getting an office to work in, but there are 3 houses which are half being offered to the Health Commission for rental.

9/4/76

Grasshoppers – I think we have a plague out here – boy is my car a mess after I've driven out in the country… I have done 5 hrs overtime this fortnight but haven’t had a chance to take it off in lieu, which means I lose it as you have to take it in the same pay fortnight. I have done over 2,600 km in my Ford now … I'm becoming very suspicious about our office. I've heard rumours that after the budget comes down the Health Commission will only be given on-going funding i.e. no money to rent extra premises and all unfilled positions will be wiped.

5/5/76

Yesterday we had a visit from the staff review committee. It was horrible – they kept asking us questions but gave no indication of what they were thinking or how we measured up – we were both quite angry when they left and we feel quite determined to start putting pressure on re: getting an office. We piled our room with all the things we could find, including all the things from our cars – and they wouldn't even sit in it. I'm starting to get fed up with working conditions in the country – especially when, added to the above, people seem to think that Social Workers are Pensions and practical assistance experts, and not much else… On Monday night I had to go over to F. to talk about Social Work and Speech Therapy at a careers night … there were about 20 people who wanted to know about these 2 careers, but I think they were more interested than enthusiastic.

12/5/76

Our office furniture was delivered today and you should have seen our little room! We literally could not move. By lucky chance Dr R happened to be visiting (the area) so we asked him to come and pay us a visit as well. Probably didn't do any good, but at least we tried… The hospital is still being difficult… (this) rubs off with the Doctors, and my predecessor at the hospital has given the town a negative impression of Social Workers.

6/7/76

At the moment my Health Commission car is unregistered – they sent the registration stickers for the community Nurse and Baby Health Sister, but forgot mine! So all in all I've had a rather frustrating day and I don’t know whether to laugh or cry.

2/8/76

We have finally got our Speech Therapist, but unfortunately she has been spirited away to the hospital because of our lack of accommodation… P. now wants a playgroup – gives me something to do which I will enjoy for a change!

9/8/76

Well we’re finally moving into our new premises for work. The Speech Therapist is to move in with us and we are getting special permission to employ a part-time receptionist despite the staff freeze.

24/8/76

We spent most of toady moving to our new office – no phone, so we are going to be in the CWA rooms until 10.00 a.m. each morning until the phone is put on … it rained nearly all day today – we picked a good day for moving – everything is now in the other building, but we are by no means settled – there are boxes, files and papers everywhere.

1/9/76

I'm starting to feel almost completely drained work-wise and can understand how Social Workers become apathetic and develop “what’s the use” syndrome. I feel that I have put so much of myself into my job, but am not being refilled. I have no-one to ventilate to, although people are always ventilating to me… It was really good to spend some time with normal families in Melbourne (at my Granny’s memorial service) for a change and to be reminded that family life can be other than one big tangled mess and fouled up communication.

25/11/76

Last week we were landed with a mother and six children from F. who had to catch the midnight bus to Brisbane. They stayed in our office all afternoon and evening. The mother was absolutely exhausted and they had all spent Thurs night sleeping on the floor of the F. Health Centre… I went back at 8 p.m. to see how they were getting along – they were all just about crawling up the wall, so I took them for a drive around town, then out to the airport to see the plane take off, then back to my flat until 11 p.m. – then back to the Health Centre where they were picked up at 11.30 p.m. by the welfare officer from the hospital and the Salvation Army Officer… I’d planned to take the afternoon off as I had been going flat out all week … but instead of that I worked overtime! (Around this time I was also daily driving 4 children to school).

1977

During this year I began a local Neighbourhood Centre by researching, drawing up a proposal, recruiting volunteers and supervising them in collating information (which was stored on cards in shoe boxes). I also became engaged and married in October that year, resigning to adjust to farm life.

 Return to work

 I did not return to Community Health until the late 1980's, beginning part-time in a nearby town, and teaching the Welfare Course at Tafe as well, before becoming full-time in the current town. During the intervening years Community Health had moved several times and had increased substantially in staff. It had also been moved from the Commonwealth to the State Government, with administration from the local Hospital. In the early 1990's a new purpose built Community Health Centre was constructed in the grounds of the Hospital, and this is the building that staff will be relocating from.

During the past 25 years in Community Health I have been involved in setting up and sustaining a Youth Support Service, a Domestic Violence Committee (which was involved in numerous projects) Social Work Group Supervision, a Women's Support Group, a Bereavement Project (which included a Support Group), Rural Crisis Workshops (and a written manual for conducting them), Health Promotion projects, amongst other things, along with providing a Counselling service and Clinical Supervision. And I wonder if the scope for providing such a wide ranging service will continue.

Rest in Peace, Community Health.

Resilience

Last week a deluge of rain and hail hit our house yard and created an instant roaring creek that flowed along the edge of our back verandah over my newly established flower beds. Initially I thought they were ruined but, after the creek had subsided, I managed to unearth all of the plants from under the mud and flood debris and found that even the tiny newly emerged Alyssum seedlings had survived. This storm taught me a lesson in resilience, which I think can be applied to our lives.

Feel the trauma and the pain

When life dishes out traumatic experiences we are allowed to react emotionally (I certainly cried), and we need time to process the shock and the feelings it generates. If we don’t allow the time to do this and think we should just “bounce back”, these feelings and reactions may become buried to simmer away and emerge again later when we are less in a position to be understood.

Look for signs of survival

Once the muddy water had finally soaked away and the rain had eased, I could go out and look for signs of survival – and the more I looked, the more I found. Instead I could have focused on looking for signs of damage (of which there were lots – hail had viciously shredded leaves of vegetables and plants, tall plants were sagging and fruit had been knocked from trees) – the dominant story.

In our lives too, we need to actively look inside ourselves for the strengths that have helped us to come through a crisis and survive rather than continue to only see the damage and losses.

Look for signs of new growth

This occurs further down the track – in my garden it was new seedlings still emerging, new leaves and flowers on plants and plants reaching again towards the sun.

In our lives, survival through traumas and crises can lead to the strengthening of our characters and the learning of new skills

The resilience building river metaphor

In one of the sessions of the Women’s Support Group we used the metaphor of life being like a river that has obstacles, white water, rapids and currents, slow and shallow sections and normal sections where we can “go with the flow”.

We talked about the obstacles being the things we have to navigate around by carefully finding a way through, and in our lives these may include fear, changes, grief and loss, difficult family members, children reaching puberty and risks of emotional injury.

The rapids are the things we have little control over and the times when we have no option but to keep going, and these can be things like going to court, dealing with government departments, moving house and things that make us really anxious.

The slow and shallow sections are the times when we have felt stuck or trapped, and these may include depression, boring times, restless times and times when we feel drained of energy.

The times we have had to climb out and rest by the river may be when we are exhausted, have lost hope, have given in to negatives or when others take over.

However the things that can give us the courage to get back in the river and continue our journeys may include being positive, learning from “the choir of hard knocks”, having people help us to do things for ourselves, encouragement and knowing we are not alone and that others suffer too.

The things that have helped us to keep going despite all of this are listed below.

Things that build resilience

With acknowledgement to the wisdom of the women in my former Women’s Support Group, some of the things which can help us become resilient are:

• Finding inner strength and listening to our inner voices of nurture and encouragement
• Learning from our mistakes
• Knowing that we have learnt something from the things that have happened
• Being able to move forward to positive things and believing in ourselves and the future (hope)
• Being able to see the big picture
• Knowing when to take time out and knowing when to ask for help
• Planning and problem solving skills and having a sense of direction
• Taking control of ourselves and our lives and giving ourselves choices
• Believing it will get better
• Motivation, confidence, skill and competence
• Sense of accomplishment

 Resilient people are able to reach out to others, overcome obstacles from the past, steer through everyday adversities, bounce back from setbacks and reach towards their full potential. (Stephanie Dowrick)