Engaging a client: Lessons learnt from Partners in Recovery
19 Dec 2016
Too often we hear people telling us that they found it difficult to get a service. That they or a loved one didn’t fit ‘eligibility.’ That they don’t try because they don’t know where to start; who does what; when do I need a psychiatrist / psychologist / another ‘ist’ On the other hand are people who would genuinely benefit from services but are reluctant to consent or sign up. People who are tired of repeating their story. People who get excluded or exited because they cannot state what their recovery goals are.
The mental health system is complex and can be difficult to navigate. The burden of illness, stigma, discrimination and lack of understanding about what is going on adds to this. The band width to get a crisis response is hard to know. Collaboration is often replaced with justifiable excuses that see our clients being shunted between services. Police bring people to hospital emergency departments, diagnostic overshadowing often means physical health is overlooked in favour of a mental health assessment and clients are often out the door before police have had a chance to get back to the station. Acute in-patient units work on such a tight turnaround that as soon as there is a softening of symptoms the client is discharged. Case management teams maintain high caseloads with a never ending demand upon them. The primary care sector is poorly understood by some components of the tertiary services resulting in a lack of referrals and an incomplete treatment team. Collaboration is again replaced by justifiable excuses. The need for strict criteria and key performance indicators are necessary evils in the way the service system operates as the alternative is a system that will be full, blocked and only able to assist those currently engaged or with service acumen.
More layers of complexity are added in the seemingly never ending reform, restructure and rebranding. What about when the NDIS comes to town? How will this affect those who are not empowered? Those who won’t apply? Those who needed to be ‘found’ in a system where previously they have repeatedly fallen through the gaps. Aren’t the jigsaw pieces all supposed to fit together to give a comprehensive, seamless service system? A safety net?
What about ‘client centred practice’ and recovery focused care and how this translates into everyday service delivery. Over recent years, there has been a move towards prevention and early intervention, but what about when the person says no! Or not yet! What about when a client says, I’ll work with you to get a job, but I don’t want to take medication or stop using alcohol or address my poor physical health. What about the pleas from family who are calling out for assistance for their ‘reluctant’ loved ones.
Of course there are also great success stories out there, committed case managers, case workers, support workers, GP’s, supportive families and carers and other professionals too numerous to mention. Over the past three plus years, Partners in Recovery has learnt some things about how to engage people and would like to share a story about a client that focuses on engagement and the valuable lessons learnt about the benefits of hanging in there, highlighting a risk that if we cannot do this work, who will, and if no one will, what happens to our clients…
Sam and WISE Employment’s story
Sam had a diagnosis of schizophrenia when he was referred by Centrelink to PIR in 2014. He was also homeless and had minimal supports in place. Sam was allocated to a support facilitator1 at Wise Employment2.
The support facilitator was able to make phone contact with Sam by November 2014 but he was very reluctant to engage with PIR as he did not trust services, did not want anyone telling him what to do or making decisions about his life.
Sam was hesitant to meet with PIR but was willing to talk on the phone so his support facilitator arranged to call him weekly for a casual chat. This arrangement was agreeable to Sam who used the phone calls with PIR to ‘vent’ about government agencies, mental health services and another matters that were on his mind. PIR maintained a neutral and supportive stance during these calls and continued to encourage him to meet up when he was ready.
After about 6 weeks of weekly phone calls, Sam asked his support facilitator to help with a legal matter. With a successful outcome there was increased trust in the support facilitator and PIR that then led to a chance to meet face to face. This was 2 months after the referral.
At the first meeting, Sam presented as highly agitated, with flight of ideas and minimal insight. He was verbally aggressive and expressed heightened paranoid thoughts especially about government and mental health services. He was reluctant to provide any information about his living situation, history or current activities and circumstances out of fear that we would ‘put him in the loony bin’.
The PIR support facilitator continued to maintain a neutral and supportive approach with Sam during this meeting and suggested weekly face to face meetings at the office to ‘get to know each other’. Sam agreed to this plan and attended the office at the same time and day each week and over the next few months he became more trusting and slowly began to open up about his life. Despite this growing relationship, Sam still remained highly distrustful and somewhat paranoid during every meeting.
As time progressed, Sam started to ask for help with daily living tasks, liaising with housing, Centrelink and legal services which was very helpful to him. During this time there was a change of support facilitator which resulted in Sam distanced himself from services and becoming uncontactable for some time. The team leader attempted weekly phone contact to him and left messages on his phone, sent SMS messages and maintained a supportive approach with client.
Approximately eight months since commencing in the program Sam initiated contact with PIR when a crisis arose. A catch up at the local shopping centre that client was familiar with was arranged and the team leader from WISE met with Sam and invited him to have some lunch. Sam requested a big bowl of corn and chicken soup which was paid for. The team leader and Sam ate together and he commented that this was his favourite meal and that he hadn’t been able to afford a meal like this in a long time.
From that time Sam has met with PIR weekly and over time he has been provided assistance with:
• clearing debts with the local council for his dog;
• organising Centrelink payment for disability support pension;
• attending a private psychiatrist review at Pinelodge Clinic for a mental health assessment and treatment plan;
• linking with a local GP who is supportive of people with mental health diagnosis;
• commencing medication which he likes;
• lodge a housing application;
• Return to study (building and construction course).
Sam’s mental health condition has stabilised and he is able to communicate effectively without becoming agitated, aggressive or paranoid. He regularly takes his prescribed medication and his mental health state has improved markedly, he continues to study part time and is due to complete his course this year.
Sam has also started some volunteer work at a local church group where he helps with meals and odd jobs. He has gained some paid work doing building and construction and hopes to set himself up as a handyman/tradesman upon completion of his course. He has found temporary accommodation staying with a friend while he waits to hear about his housing application.
Staff at Wise comment:
“Overall it took a very long time to gain Sam’s trust and build rapport with him, but we didn’t give up. We did what we told him we would do, showed him we could be reliable and trustworthy and supportive and over time he came to believe. In turn, Sam opened up and let us help him.
These days Sam still wants to be linked to the PIR program as a safety net. We have monthly phone contact and the occasional face to face visit at the office, however these days it’s usually Sam who rings me to fill me in on all his news!”
So, in summary, what worked?
• Non rigid adherence to set KPI’s. (PIR has a KPI that all assessments occur within a month of referral)
• The built in flexibility of a model that is care co-ordination but can dip in and out of a case management role as required.
• The concept of rolling consent. Being ok with an agreement to ‘call you next week’ and not insisting on signing a form!
• Tenacity and endurance as key traits in the workers delivered in a non-judgemental way.
• A system that isn’t keen to progress you to the next stage and if you do well, there is still support offered.
• Ability to use funding in a flexible way
• Taking a recovery focus, centred on what the client wanted and being comfortable to sit with symptoms
• Being consistent.
1Support facilitators are the staff who deliver the care coordination
2Wise employment are one of five hosting agencies delivering PIR