Over five weeks ago I was approached by one of my patients on the unit who let me know that he hated his life. He talked about the various experiences he had and he was concerned that a short stay in rehab wouldn't offer him the opportunity to find any kind of comfort or relief. I suggested that rather than thinking about changing everything we could begin to think about small changes and that I would help him to begin to institute those changes. He was quite skeptical and as I expected he began to argue that my approach wouldn't work - he engaged in what my grandmother called 'arguing your limitations'. I certainly understand as I was aware that he was scared and when you're scared your world feels really small. It makes sense to me that he was resistant: fear is all he knows and I am asking him to trust me (he doesn't know me that well), and that I wanted him to try a different approach - while he is scared and his way doesn't provide the kind of comfort he wants, he knows his way rather well and to some degree he feels safe. I was asking him to give up his way and try a different approach.
When I am working with family members or a patient I don't see them as cynical, resistant, or pessimistic, I see their "stuff" as fear. Seeing their responses as fear helps me to relate, it humanizes them versus attaching a pathology to their responses, and allows me to tailor my approach to their response. When my patient was upset and I saw his 'stuff' as fear I could work with that and not personalize his unkind responses towards me. As I began to think about him I had a few ideas he could begin to implement:
1) I suggested that he follow-through with an appointment with one of our psych med providers on staff. It was apparent that while he had a history of addiction, his psychiatric history was impinging on his ability to navigate the day-to-day functions of the rehab schedule. I was able to arrange a time where he could meet with a psychiatrist who specialized in addiction and a history of co-morbid disorders including anxiety and depression. Three days after he began taking medication he started to feel better, he started to sleep 6-7 hours a night, and his thought process was better in that he no longer had intrusive thoughts and he didn't feel distress. It's not that I am a magician, rather, I know that medications can serve a purpose and the team was able to support him to find a combination of medications that worked for him.
2) He didn't have a place to live after discharge as he burned his bridges with his family and after discharge without housing he would be homeless. I spent time considering the options for him and realized that clean and sober housing in addition to a case-manager to follow him would be the best bet over independent living. I talked with his mother and step mom and they were willing to support him financially for a period of time.
3) He had limited vocational skills that could offer him a way to support himself. In the state where I live addiction is considered a disability. There are various agencies that were able to take into consideration his health history, his mental health diagnosis, as well as his history of addiction. While he has yet to follow-through, he has the ability to pick from seven different careers that will offer him a living wage. Supporting someone with the best addiction treatment available is useless if a client doesn't have a place to live or the ability to support himself. The programs I located would give him an opportunity to work while offering him the ability to develop pro-social activities.
As I started to work to develop a safety net for this client and he began to see all of the paperwork he had to sign with the various appointments he had to attend he began to understand that I was on his side. His resistance diminished and he apologized for his earlier statements. I didn't expect nor need an apology, however, his apology let me know that he began to trust that we were on his side.
4) I made several calls to various mental health providers with him present and he began to interview various people that provided mental health counseling. I suspected that he would do best with day treatment, however he surprised the team and decided that he would rather pick an individual provider and take the bus to various mental health groups and support linkages available to him. He took the initiative to develop a schedule and showed me how he was going to attend each group and what bus he needed to take to make it to his appointments on time. I was impressed with his ability to utilize the available resources and get his needs met.
5) We looked at two different volunteer sites: Service Leader and VolunteerMatch. He found four different volunteer gigs that suited him and filled out the applications and we faxed the applications to the agencies and made sure he added those dates to his calendar.
6) I knew that he needed a phone so we filled out an application for Assurance Wireless as well as a free community voicemail provider. He has cat and he was given an application from the Humane Society as they do free pet food delivery for low-income clients. He had dental issues and we filled out an application for Donated Dental Services, an organization of volunteer dentists that provide free denial care. He needed better money management skills so we found a org that will pay his bills and send him a set amount of money every week so that he has a bit of spending money. We filled out an application for a reduced fare bus pass, and finally we made sure that his mediations were sent to him on a monthly basis.
Before he left treatment he wrote an extensive letter outlining his desire to follow-through and pointing out various things that were important to him. I am keenly aware that we spent a significant amount of time with this client and it took a herculean effort to connect with people that were even willing to take on someone with his his history. I am under no delusion that setting up all of these providers insures success, however........I am also aware that the best counselors don't always maintain perfect boundaries. I am sure that some people could argue that he should have probably done most of the work, but really, was he capable, especially when he was easily overwhelmed? Is it possible that he will be overwhelmed by the sheer number of appointments and that he will probably miss a provider appointment even though he has a schedule? Absolutely. What's the alternative? It seems to me that supporting someone to find options and then teaching them that people want to help and that the world isn't always a scary place is better than letting someone suffer. I'm okay with what we did.
Guess what? Today found me getting a letter from this client letting me know that he had been sober for 33 days...this is the first time he's been sober for 33 days in over 20 years since his first attempt at recovery. He let me know that he started exercising and that the judge threw out two of the three legal charges. He is required to stay on probation for a year and follow-through with some kind of service work. Apparently the volunteer work he's currently doing will count towards the court requirements.
Hmmm, yeah, I'd say this was successful.