Welcome to the March edition of Tips and Topics and to all the new subscribers.

In SAVVY, two staff scenarios raise some clinical supervision and organizational development learning lessons. One has to do with clients who show up late for appointments and the other is when staff feel unsafe with clients.

In SKILLS, these two scenarios highlight the skills needed in supervision and organizational interventions to first assess the situation and needs before taking clinical and organizational action.

In SOUL, I have decided to down-size and live in a turn-key situation that makes it easier to lock the door and travel free from the responsibility of home maintenance. I quickly offered to buy a townhouse that had just come on the market, then abruptly yanked my offer when considering the downsides. Fools rush in where angels fear to tread, or Opportunity knocks but once. So which is it?

Recently, I was consulting with a Clinical Director about two staff situations that had caused supervisory and organizational development challenges.

Scenario 1

It is not unusual with a client population that suffers from addiction, trauma, severe mental illness and co-occurring disorders for them to come late for their assessment appointment. It could be 15 or 30 minutes late and some even two hours. Some staff members have become increasingly frustrated to the point that they simply tell the receptionist to inform the client that they need to reschedule.

Tip 1

For any client behavior that is “inappropriate”, antisocial, and especially if annoying, the first step is always to speak with the client in person and be genuinely curious about what happened to cause the behavior.

In the behavioral health world and actually in healthcare in general, person-centered care includes, but is not limited to the following practices:

• Recognize that clients may be overwhelmed, disorganized and dysregulated. They first need to feel respected, accepted and welcomed for making the effort to show up.
• Recognize our own feelings of annoyance and frustration. Remember that our job is to engage and attract a person into a self change process, not demand compliance with what makes us feel comfortable....it’s not just about us; it’s about them.
• Develop skills to calm, de-escalate, understand and empathize with the client’s distress and behaviors.

Scenario 2

A counselor assessed a client who seemed to get increasingly frustrated with all the assessment questions he had to answer. He started mumbling to himself and his legs were anxiously restless. When asked if anything was bothering him, he said “no”, but continued to appear frustrated. He asked for a pen to write down some information. The counselor started to feel unsafe as the desk was positioned in such a way that the client was near the door, which would block any need to quickly exit. The counselor started feeling that the client could use the pen as a weapon and asked Security to escort the client from the building.

           At a systems level, the counselor asked that a panic button be installed in the office. In addition, when it was determined that the desk could not be moved to allow the assessor to be near the exit door instead of the client, there was a request for some kind of window to be installed in case any cry for help could not be heard.

Tip 2

It is the organization’s responsibility to ensure the safety of all staff. However before making structural changes to the building, assess whether there are safety improvements needed and/or whether the staff member’s fears indicate assessment and skills deficits.

Feeling unsafe in client interactions can be the result of inadequate safety protocols and organizational supports like panic buttons, office layout and availability of security officers. However, feeling unsafe, like “resistance”, can also be more of an interactive process saying as much about the clinician's lack of skills as it does about a client or organizational problem:

• When feeling unsafe in any client interaction, first assess for imminent danger just as one would if a client were to mention suicidal thoughts.
• There are assessment protocols to evaluate aggressive words, thoughts and behaviors just as there are for suicidal words, thoughts and behaviors.
• Assess both the organizational safety protocols, building and office layout; and staff attitudes, knowledge and skills on how to assess and address situations of unsafety.
  

SKILLS

Scenario 1

What are the clinical and organizational SKILLS needed to assess and address annoying client behaviors? How to move from expecting compliant client behavior to engaging people in a self-change growth process? Person-centered care helps decrease the client’s annoying behaviors AND improves staff serenity and smooth organizational development.

Tip 1

Balance a person-centered, service mentality with necessary, but not sufficient self-care interventions. The organization creates the environment to support staff to be “person-centered”.

When people choose to work in healthcare, they are choosing to be in the “people business” not just business facts and figures or the assembly line. There is an occupational hazard to get overwhelmed with all the pressing client and documentation needs to the point of unbalanced self-care burnout.

• It is the staff member’s responsibility to maintain self-care so they can show up ready and centered enough to do the “people work”.
• It is the organization’s responsibility to ensure that policies and procedures, scope of work and job responsibilities are reasonable and doable without burning team members out.

Tip 2

How to approach, assess and address a client who is late to appointments.

Remember that clients may be overwhelmed, disorganized and dysregulated. On top of that they may also be frazzled and fearful about being late to an authority person who could give them a “bad” assessment. That “non-compliant” evaluation could result in loss of welfare benefits, parent visitation or custody rights or housing.

• Meet the person in the waiting room and thank them for showing up while also indicating how late they are for the appointment.
• Acknowledge that making it to an “in person” appointment takes a lot of effort to remember the appointment, navigate public transportation, a broken down car or finding a ride.
• Do a quick review of the reasons they are late: Forgot the time; transportation problems; intoxicated or cognitively disorganized; emotional dysregulation or flare up of addiction or mental health symptoms.
• If there is potential imminent danger due to severe intoxication; psychotic disorganization or impulsivity to harm self or others, address that immediately.
• Indicate that if they can wait, you will see them for a full or partial assessment when you are available.
• Give them the option to wait or reschedule.
• When you are able to spend more time with them, ask what happened that they were late and assess the addiction, mental health, environmental or social issues identified e.g., intoxication, mood or cognitive dysregulation, lack of money, transportation, or supportive friends or family.

Scenario 2

What are the clinical and organizational SKILLS needed to assess and address staff feelings of being unsafe? When is the right time to make organizational and structural changes to address safety? When should the emphasis be on staff attitudes, knowledge and skills to address feeling unsafe?

Tip 1

Assessment skills to evaluate frustrated, aggressive or apparently dangerous client words, thoughts or behavior.

Most clinicians and counselors whether in the addiction or mental health fields are relatively comfortable to assess suicidal words, thoughts or behaviors. They know when there is imminent danger and what to do; or what to do if not imminently suicidal. The process of evaluation and next steps are similar when addressing behaviors that make the staff person feel fearful of aggressive behavior.

• Is the client so intoxicated or psychotic and impulsive that they could immediately act on any aggressive thought or impulse? If not, there is no need to involve a Security Officer or other staff to assist.
• If the client says they are not annoyed, frustrated or angry but is acting as if they are, use Motivational Interviewing skills to compassionately enquire and evoke from the client an understanding of the behaviors e.g., mumbling to himself, restless leg shaking, poor eye contact etc.
• Pivot to other ways to address any behaviors or fears that make you feel unsafe. In this scenario, if the staff member worried that the pen the client was using could be a potential weapon, ask for the pen back and offer to write down the information for the client yourself. Or move your chair from behind the desk to position it closer to the door and work with the client chair to chair rather than from behind the desk.
• Review the client situation and feelings of safety with your supervisor to see what other assessment and skills could be added to your knowledge and/or whether there are organizational and building changes that need to be made to ensure safety for staff and clients.
• If there are organizational and building changes to be made, the supervisor passes those onto the appropriate leader in the organization.
• Recognize that unnecessary involvement of Security officers and a show of force can be triggering and re-traumatizing to clients and that we are also responsible for “doing no harm” not just addressing our own needs.
  

SOUL

I have decided to down-size and live in a turn-key situation that makes it easier to lock the door and travel without worrying if a tree will fall on the neighbor’s (or my) house while I am away...or if the roof will leak. Soon after settling on that decision, a townhouse in a great location with beautiful old tree growth and setting came on the market. I pounced with an accepted offer all in less than a week. When else would I find a place in such a convenient and pleasing location? FOMO (Fear of Missing Out) took over and I thought of “Opportunity knocks but once”.

But as we did due diligence on this old, pre-asbestos and lead safety regulations, it became clear that any renovations would involve expensive and time-consuming remediation work. I would be exchanging the hassle of maintaining the big family home for construction and remediation hassles in a small, old townhouse. “Fools rush in where angels fear to tread” came to mind.

So which is it? Opportunity knocks but once or Fools rush in where angels fear to tread? Is it Either-Or; or Both-And?

As I continue my search for suitable place in which to down-size, that FOMO townhouse brought lots of clarity on what I really want in the next opportunity. Now I am ready to not foolishly rush in. So it’s Both-And. I don’t have to be either paralyzed by indecision fearful of the wrong decision. Nor though do I need to rush in with FOMO and have buyer’s remorse.

I remembered I wrote about Either-Or and Both-And in SOUL back in January 2004. It is still relevant 20 years later in this season of political and election fear mongering about the other side.

As I wrote 20 years ago, “I know it is probably naively idealistic to think we could ever be a “both-and” society instead of an “either-or” one. It is tempting to only see my resolve and his stubbornness; my determination and her block-headedness; my compassion and her wimpiness; my assertiveness and leadership and his aggressiveness and control problem. But in this season of adversarial politics, might it just be possible that you and I at least, might try to resist the “us against them” mentality?”

P.S.

I am writing this month’s Tips and Topics in beautiful Hawaii. Comedian Jim Gaffigan’s brief, but funny and sobering piece happened to pop up in my social media...just had to laugh and share it.

UNTIL NEXT TIME

Thanks for joining us this month. See you in late April.

David