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October 2009 – Tips & Topics

Volume 7, No. 7
October 2009

In this issue
— SAVVY – Lessons from Case Conferences
— SKILLS – Helping People Help Themselves
— SOUL – Common Problems often not Common Knowledge
— Until Next Time

Welcome to the many new subscribers to this October issue of TIPS and TOPICS.  Welcome back to readers, some of whom have been with us for over six years.


When you are working with a client for weeks, months and even years, it is easy to be so close to the situation that you lose perspective. This past month I had the opportunity to interview several clients in front of the treating clinician and the rest of the clinical team.  The clients were all agreeable to a case conference; and some were even enthusiastic about having a consultation with an “expert” psychiatrist from out of town.  Here are two clinical vignettes garnered from these live interviews along with learning points from my outside look into the hard clinical work with these clients.

Names and details have been changed to protect confidentiality.


  • Long lengths of stay in residential and inpatient settings can induce regression with unintended negative consequences for some clients.

John is a 30 year old, divorced man with suicidal ideation who recently was approved for disability payments for depressive illness and suicidality.  He has been a patient in the acute State psychiatric facility for eight months.  Whenever he nears a date for re-integration into the community, he invariably becomes suicidal and is unable to be transferred back to the community. In recent weeks, much of the staff time has been focused on his hurt and anger at feeling disrespected by some staff as well as his various annoyances about not getting snacks when he wanted or having to go to certain treatment groups.

Learning Lessons

–> With acute psychiatric and crisis beds focus should be on stabilizing and preparing a client for linkage to outpatient services.  This is especially important for those who have borderline personality issues and can regress in intense inpatient settings.  In such total care environments, inherently there is the danger for “Parent-Child” interactions when “Adult-Adult” clinician-client interaction is what is needed.

–> Since so much time has been spent on his anger at staff, it is important at first to acknowledge and empathize with his frustrations. Without doing this, it will be hard to redirect him to the original problems which prompted his admission to the psychiatric unit in the first place – i.e. his tendency to run away from problems or take it out on himself in suicidal ways. This can be achieved by using his current hurts and disagreements as opportunities to practice new ways to avoid running from the conflict (he was agitating to be transferred to another unit to avoid staff members) or to become suicidal (to escape).

–> It is an occupational hazard of working in acute and crisis settings to take on a “Parent-Child” stance and enforce program rules about for example, snacks or group attendance. The client contributes to this kind of interplay by regressing into oppositional, avoidant or defiant reactions that keeps the cycle going.

–> Clients who have suffered early inconsistent parenting can develop personality problems, feeling a strong need for nurturance, but an equally strong fear of abandonment.  If such clients are approached with a lot of support and nurturance alone, this fulfills the strong longing for care.  But it equally stirs up fear of loss and abandonment which causes the client to fluctuate in their mood and level of engagement.  They may switch from an apparent working relationship to one of anger and rejection as their fear of abandonment and loss also arises.  The client creates a distancing move to protect himself from what he perceives is the inevitable rejection and abandonment.  Rather than be rejected, he feels compelled to create distancing and personal safety.

–> Find the balance between this need for nurturance and the accompanying fear of abandonment. Pair together nurturance and reassurance with an equally important focus on the client’s responsibility in treatment.  This helps maintain a healthy and safe distance.  “I can help you and hang in, BUT it won’t be easy and I can’t do it all.”  “I know we can help you, BUT you have to work hard as there are no magic answers.”  “I know you can be successful, BUT you have to work on all your issues and show up for treatment as I can’t do it alone.”

–> So for John, the treatment plan should specifically document problems and priorities in client-friendly terminology that makes sense to him.  Treatment plan goals could be: (1) identify how to prepare to return to the community and (2) deal with frustration, depression, anger or hurt in ways other than running away or hurting himself.

–> Because of the inherent danger of regression in acute inpatient and crisis settings, particular attention is needed to design the therapeutic milieu. It should create and promote a culture of health and functioning rather than a focus on pathology and compliance with unit rules and staff directives.

  • When a client does not follow through with your treatment recommendations month after month, don’t look at the non-compliance of the client, look at the non-alignment of your goals with the client.

Derek is a 53 year old divorced, employed auto mechanic diagnosed with Schizoaffective Disorder and Alcohol Dependence who also is reported to have a gambling problem.  The consultation question on Derek was how to engage him to follow through on alcohol abstinence and his gambling problem (playing slot machines).

Derek was happy to be interviewed. He opened the interview saying he was letting his therapist and others down by not following through with any treatment for alcohol use, and not taking care of his gambling problem.  I asked how his drinking and gambling were affecting his finances. Were there any dangers of losing his job? Did he have any legal issues pending? Derek stated there were no negative consequences he had experienced. He said he spends about $200 per week on gambling, but has enough money for food and rent.  He drinks three beers a day and more on weekends.  He uses mostly alcohol now and no other drugs even though he had used a variety of drugs 30 years ago.

Over the years Derek has had many counseling sessions, but he is most focused on not getting paranoid again so faithfully gets his intramuscular antipsychotic injection every two weeks.  He understands in order to be allowed medication he has to agree to counseling. Derek talked freely about low self-esteem and how he doesn’t follow with what his therapists have told him to do.  He really sees no problems with the level of drinking he now does nor with the amount of money he spends on gambling.

Learning Lessons

–> To engage any client, focus on the What, Why, How, Where and When to identify what is most important to the client at this point of time.  Clearly Derek wants to do whatever he has to in order to keep getting his medication which he believes prevents recurrence of paranoia and unstable mental illness.  He is not interested in sobriety and stopping gambling; he only appears to work on these in order to please the counselor and meet what he understands is the rule (i.e. see a counselor to keep getting medication.)

–> He talks of having low self-esteem. When asked what he wants to work on in counseling, not what others think he should work on, he has a hard time speaking up for himself.  This makes it all the more important to resist the impulse to tell him what to do.  He willingly goes along with this approach because he sees his role in life is to please others. He agrees to counseling because the policy requires that, not because he has something to work on in therapy.

–> I suggested to Derek that he stop drinking and gambling when he was ready to do that rather than “pretending” he’s interested in working on that.  When he does not succeed, it perpetuates the idea that he does not follow through and lets others down. This keeps him in a disempowered one-down position and reinforces his low self-esteem. So the cycle goes like this: Tell your client what he needs to work on whether he wants to or not; have him repeatedly fail and “let you down”; and then tell him he didn’t follow through.  Now he fears he will be removed from the help he does want (medication).

–> You should continue to have an ongoing assessment and keep monitoring his alcohol use and gambling. Check that his job is not threatened by his drinking or gambling behavior; that he has money to pay his rent and for food; and that there are no negative consequences of his behavior, legally or relationship-wise. If he continues to function adequately, there is no immediate need to urge abstinence from alcohol or gambling.


One of the benefits of fulltime training and consulting is I get to learn from others’ experience across the country and internationally.  Here are a couple of tips I learnt from workshop participants who passed on wisdom they received from supervisors or from their own experiences.


  • In every interaction you have with your client, ask yourself: “How is what I am doing today helping the client to help themselves?”

Some clients with severe and long-term illness may need some level of professional help indefinitely.  Many others may not.  So our work is to:

–> Provide the opportunity for people to harness their own self-change and growth process.  Do you approach a person with an attitude of service as you would a customer, rather than a client to be treated?  Can you inspire a person to imagine the possibilities that right now may be dim for them in their hour of crisis?  How do you keep hope alive for this person at this time?

–> Resist the impulse to create an environment of dependence and compliance. This can be challenging when family, courts, child protective services, judges and probation officers, employers and schools pressure you to fix a person.  Is your work setting one where people feel intimidated to follow rules and regulations?  Do you approach a person with an attitude of prescribing treatment with which the client must comply?  How does your setting dampen a person’s assertiveness and sense of freedom to speak up for what is important to them?

  • Ask a client: “Is there anything you can think of that might make it hard for you to follow through with this plan?” Then allow sufficient time for the client to actually think about that and respond.

A consumer at a workshop shared her experience of being told what to do in her treatment even though it had little to do with what was most important to her. For several weeks she tried not to alienate her therapist. She attempted to disagree with the focus of her treatment without being disagreeable.  She was feeling vulnerable and dependent enough that she kept showing up. She was fearful enough of rejection that she tolerated many sessions which left her unsatisfied and frustrated.

Finally, she mustered up enough courage to blurt out that she was not getting the help she needed.  The world did not blow up in her face.  Her therapist apologized for being out of sync with what was important to the client. Also her therapist explained she had interpreted the client’s hesitancy as her resistance to change some difficult situations.

I complimented this consumer for her courage to speak up.  However I also said it would have been a lot better if the therapeutic environment had been different. A consumer should not have to reach such a frustration level before mustering the courage to assert his/her power.

–> Think about the last time you went to your primary care physician.  You are a professional person and pride yourself on having good self-esteem and being assertive. Your physician is competent and concerned, but always very busy. You’re aware of many people in the waiting room. You have your appointment, but walk out of the office still unclear about the doctor’s explanation of your medication or lab results. As you get to your car in the parking lot, you ask yourself how come you hadn’t slowed him/her down to give you a more detailed explanation so as to assure your full understanding of your medical issues.

Many clients feel in a one-down position just having to walk through the door to your clinic, office or program.  If they had no self-esteem problems, fear of rejection, anxiety, depression, overwhelmed feelings or paranoia, they wouldn’t need your services in the first place.  Make it easy for them to speak up: “Is there anything you can think of that might make it hard for you to follow through with this plan?”


Do you wash your hands after you’ve gone to the toilet?

What kind of question is that, you ask.  And anyway it’s none of your business!

I was listening to Science Friday on National Public Radio.  A recent study in England published in the American Journal of Public Health found that only 2/3 of women wash their hands after using the toilet and it’s even worse for men.  Only 1/3 of guys wash their hands.  Dr. Val Curtis, Director of the Hygiene Centre at the London School of Hygiene and Tropical Medicine (part of the University of London) has studied this issue mostly in developing countries, but it is a problem everywhere.

In developing countries, 2 million children die every year of diarrheal diseases – that’s more people than those who die of malaria, measles or HIV all put together.  Hand washing with soap is the most cost-effective intervention to prevent deaths from diarrheal and respiratory diseases (like the flu in general and in particular H1N1 flu.)

Well this is not a Public Service Announcement per se.  What caught my ear more was how we are often oblivious to the gravity and expansiveness of a common problem. We are influenced more by whatever information feeds we choose; or maybe it’s whatever the media deems newsworthy; or whatever information is either deliberately hidden from us, or not.

For example: Imagine if you picked up the newspaper and read every week that a plane crashed and killed 226 people.  This is the statistical equivalent of how many people in 2008 were killed in drunk-driving car crashes every week of the year in the USA.

President Obama just declared the H1N1 outbreak a “national emergency”.  Deaths from H1N1 so far have been 946 in the USA (  So about the same number of people die every month from drunk driving as have died from H1N1 flu since the outbreak.

I am not diminishing the flu emergency.  But where is the public outcry about drinking and driving?  Who even thinks much about washing your hands after the toilet?  What grabs the headlines may not always be the most significant public health priority.

Until Next Time

See you later in late November.


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