The Power of Routine

I don’t particularly like most holidays and can have a bit of a problem with vacations. It’s not that I don’t enjoy leisure, it just really throws off my routine when the rest of the world shuts down and I’m not able to do the things I normally do. I know that probably sounds incredibly self-centered, but hear me out. It is, and I readily own it. My life without routine would be unbearable.

When I worked as a child and adolescent therapist I would often talk with children and parents that were living in chaotic households. Everything seemed to be reactionary rather than planned. No one knew what to expect and, therefore, they lived under constant duress. It has been pretty well-accepted amongst most therapists and counselors that children will be more healthy, emotionally and otherwise, if they have some sort of positive structure in their lives. The great difficulty I faced with my clients’ parents was that they had no way to provide (or impose) consistency for themselves or their kids. Over time, as I learned through trial and error how to help them with this, I realized that it is not just children that crave structure, but all of us.

I have many friends in the medical field with all different kinds of schedules. While some love working ten or twelve hour shifts so they can have shorter work weeks, I cannot imagine doing what they do. I like knowing that, when I get up in the morning from Monday through Friday, I am going to go to work. I’m going to get ready, hit the coffee shop, and get on the road to see my patients. When I’m finished for the day I’m going to go home and work out. After that, I will typically know what’s next depending what day it is. Monday night is time to grab a cup of coffee and chill out, maybe to do some writing. Tuesday night is a recovery meeting. Thursday night is coffee with a friend. I have several hobbies and I make sure I have time for them. I try to balance my marriage with the rest of my life. I crave stability.

This used to sound boring to me. I had, however, made the mistake of equating routine with boredom. On the contrary, routine and time management help me lead a more productive and dynamic life than would ever have been previously possible. I schedule time to write, to play music, to meditate, and just to hang out with my dogs. I have dates with my wife and attend the same three recovery meetings every week. I try to maintain enough flexibility that I am ready if something unexpected comes up (like when I’m on call for work), but generally have an idea of what I’ll be doing otherwise.

I have found that developing daily plans is as vital to my continued well-being as anything else I do. I think of them as the necessary guidelines that will ensure I am able to achieve the things I want while leaving me with enough free time to do things that may arise spontaneously. Thus routine and boredom do not go hand in hand.

An important caveat is that I find too much rigidity to be a bad thing. It is sometimes good for me to be challenged by the unexpected so that I learn to adjust on the fly, but I cannot overstate the power of routine in my life. Without it I’m pretty much floating around out there, waiting to react to things rather than making things happen. Until next time.



A Gentle Approach to Dementia

When I first became a hospice social worker I was taken aback to realize that more than half of my patients were diagnosed with advanced dementia. I had been under the assumption that I would be working with mostly people with cancer or other chronic illnesses such as COPD (Chronic Obstructive Pulmonary Disease) and CHF (Congestive Heart Failure). While many of my patients have suffered from those maladies in the latter category, the prevalence of dementia is rather high. After seven years as a social worker “in the trenches,” I would have to learn a whole new skill set if I was to survive and thrive in hospice.

Most of these patients eventually end up in nursing facilities as the burden of their care becomes too great for family members to keep them at home. In visiting such facilities I came to find that many more people than just those in hospice were in various stages of dementia. It is a fascinating phenomenon with several different causes, but I have developed my own way of working with these individuals based on their current level of capability to engage interpersonally. That being said, I have also acquired several pet peeves regarding the treatment they receive from other medical professionals.

Aside from the ways dementia affects different people on a physical level (ability to ambulate, muscle contraction, etc.), the mental symptoms range from extreme forgetfulness to devastating interpersonal impairment. I have had some of the most pleasant conversations of my day sincerely answering the same three questions over and over again for an hour with the same patients, ones who are able to converse, but have little to no short term memory. I have also spent much time in constant redirection and assurance with people that can no longer recognize relatives with whom they have spent the last eighty years. I have seen these individuals coddling realistic looking baby dolls as part of their care and have played music for people that are nearly catatonic, only to watch their bodies come alive with movement at the faint and automatic memory of their favorite songs, something that blessedly seems to remain long after their ability to speak has faded. I have heard ninety year old patients insist that their mother had just been to visit them or that their young children were running around the facility.

The common thread with which I approach these wounded patients is a measured gentleness that preserves their dignity and, to the greatest possible degree, facilitates their comfort in the immediate moment. For most of these people the present moment is all they have. Thus my preferred method is to redirect them in conversation and to by no means challenge their obviously factually incorrect assertions with harsh reality. If an elderly woman whose mother has obviously passed insists that she must know when (her mother) will be visiting, I will respond that she’ll probably be around later. I have witnessed facility nurses and aides confronting such patients with the fact that their mother will not be visiting because “she’s dead,” repeating this every time the person asks. I will just as gently take such workers aside and explain that they are effectively breaking the news of the death of a patient’s loved one several times a day, each instance with its own accompanying trauma.

Another pet peeve is when I see people with dementia being treated like children because “they don’t know any better.” Almost every culture in the East has, currently or at some time in their history, had a practice of revering their elders simply for the fact that they have lived longer and accrued more life experience than most. Watching people with little wisdom earned through the kind of adversity their patients have faced treat said individuals as mere nuisances to be quieted makes me sad to say the least. I labor under the belief that my patients are people, whether they be completely lucid and able to participate in conversation or if they are unresponsive. As such, I also believe that each of these persons have the right to my full presence and attention and that, while their minds may have been rendered functionally impaired, their spirits are perfectly intact and engaging with mine. In short, I am no better than these people just because my mind is still functional.

Lastly, watching the pain endured by the family members of such patients is nearly unbearable. They faithfully and dutifully make their regular visits in the vain hope that they will see even the briefest signs of recognition in the eyes of their loved ones, only to inevitably leave disappointed and heartbroken. They deserve to know that their family members are being treated with the highest level of respect and dignity and with a kindliness and gentleness reserved for the most vulnerable amongst us.

Please remember this the next time you encounter a person with dementia. They are locked in a special kind of hell that I hope you and I will never have to experience.



There is no cookie cutter approach.

I learned many interesting and useful theoretical perspectives in school and couldn’t wait to apply them in the real world. Psychodynamics, systems theory, and CBT were just a few of the approaches that most appealed to me. I was convinced that I would be able to instantly size up my clients and make a certain intervention fit their circumstances based on whichever theory I was most interested in at the time. I was basically trying to choose the therapeutic model I would utilize regardless of which specific client I was seeing.

I soon discovered that this was akin to deciding which tool to use regardless of the details of a construction project. You wouldn’t use a screwdriver to drive nails, nor would you try to place screws with a hammer. You have to assess the project, then decide the most appropriate methods to achieve your goal.

Thus I learned that there is no cookie cutter approach to therapy/social work. Every person is unique and possesses the ability to respond to specific interventions while being resistant to or unable to grasp others. It is crucial to have an understanding of various theoretical perspectives and to have your own “bag of tricks” (I include that term because it is often heard amongst professionals, but I strongly dislike it as I don’t believe in “tricking” clients–I prefer “repertoire”) from which to draw inspiration, but perhaps the most important ability for a social worker is the ability to conduct a thorough and unbiased assessment of each unique situation in order to ascertain the most appropriate course of action.

It is not uncommon that a client’s treatment will draw from various schools of thought as there are many creative and useful systems from which to pull inspiration. It is highly likely that, as your career progresses and you accrue more experience, your personal “eclectic” approach to practice will become a natural part of your assessment/treatment process. I have found that I have developed a greater ability to shed my ego when working with patients in order to place the focus on them because I have a greater understanding that it is not my job to make something magical happen each time I meet with someone. Change is usually a slow, steady, and sometimes painful process, and you cannot force it to occur any more than you could coerce a flower into blooming before it is time. The key is showing up, actively listening to your clients, and utilizing your interpersonal skills to collaborate on a plan of care that will effect positive change.

Remember–it is not about you and your superior knowledge of cutting-edge therapeutic techniques. None of them will do you much good if you haven’t developed the ability to perform an effective assessment.



The Power of Hello.

During the course of my day I encounter far more people than just those with whom I am working. For instance, when I go to a nursing home to visit a patient I pass many people in the hallways, behind the nurse’s station, and in the activity rooms. I have a habit of saying hello to almost everyone I pass and make sure that, when I am addressing a person in a wheelchair, I look them in the eye and smile at them as a form of acknowledgment. I have come to realize that this is definitely not the norm. People are used to walking by each other without making contact, as if we are all just things that become blurred into the background of daily life. My practice of active engagement has made quite a difference in my life.

I began to notice that I was having little conversations here and there with all kinds of people and that relationships were developing as a result. Nurses and other employees at facilities would appear to be happy to see me and we would immediately begin to discuss what had been going on in our lives, whether it be school, kids, dogs, or vacations. The same thing has long been happening at the coffee shops I frequent. I am a self-confessed java junkie and have at least three places I regularly go, each one with a different set of people with whom I have become friends.

This started happening in my life because I made the initiative to say hello or ask how someone’s day was going, then actually listened to what they had to say. I believe that most people crave connection with others, but this has (ironically) become more difficult in “real life” as we move toward cultivating more acquaintances on social media. We pay for our gas at the pump, go through drive thru windows, and generally have less and less human contact as time goes on. My interactions and relationships with others, whether they develop into good friendships or remain kindly encounters, are the things upon which I place an absolute premium in my daily life. I can not imagine how less rich my days would be without them.

Remember the power you have to effect change in your own life and the lives of others by simply and genuinely saying hello to people. It will never fail to improve the quality of your day.



Learning to Communicate.

I was told that my MSW program would provide me with everything I needed to be a confident practitioner from my first day out of school. While I did complete the equivalent of five practicums during my graduate program, each of which was essential to my professional development, as long as I was still attending school I was heavily involved in writing long, scholarly papers filled with fancy, seventy-five cent words in order to earn high grades. My specific audience consisted of professors, many of them PhD’s that hadn’t worked directly with clients in years, if not decades. I have, if not a disdain, a healthy skepticism of tenured professors with doctorates that spend all of their professional lives in the proverbial ivory towers. My favorite teachers were usually adjunct professors that were still very active practitioners and, therefore, had real-time, real-world experiences to bring to the table. My in-classroom academic career thus led me to a place far away from the populations with whom I would later find myself working.

My first post-graduate school job was in community mental health working exclusively with children and families that either had Illinois Medicaid or no health insurance at all. The majority of my clients came from single-parent homes and were, like their parents before them, academic underachievers. Their emotional and behavioral concerns were paramount and they usually lacked enthusiasm and motivation to change. The last thing they needed was one more person with whom they could not relate lecturing to them. As can be the case with new graduates, I was armed to the teeth with magical tools bestowed upon me by the Keepers of the Knowledge (i.e., the aforementioned professors) that would enable me to quickly bring about miraculous change in the lives of my clients. I didn’t realize that, as vast as your repertoire may be (and mine was not nearly as impressive as I thought at the time), none of it means anything if you don’t know how to effectively communicate with people on their level. No therapeutic connection will be made under those circumstances.

While I saw many of the theories I had learned at work in people’s lives, I couldn’t very well use terms like “system equilibrium” or “anticipatory grief” with my clients. In short, the concepts I had learned would prove to be both vital and useful, but the language I had used to make a pretty package of those same concepts in order to impress my teachers was not only ineffective, but counterproductive when trying to explain things to the people that came to see me on a daily basis. I had to learn to listen in order to assess each person’s ability to communicate. To accomplish this I had to ditch all preconceived notions I may have had regarding the ability of each client to actively engage in and understand the therapeutic process. Once I committed to making this a part of my everyday practice, I noticed how I came to understand my clients more clearly. It turned out that listening closely to determine their level of engagement had the added benefit of giving me a much clearer all around picture of the things that were greatly affecting them.

Do not assume that, just because you have a store room of fancy terms for which you paid quite a bit of tuition, your clients will be able to grasp what you are saying. You just may be alienating them and making it more difficult to build trust and rapport. It’s not about our fancy educations, but how we can take our knowledge and experience and translate those into effective tools to meet our clients wherever they may be on any given day.



Control what you can so you can deal with what comes up.

Every social work job I’ve had can be divided into a couple of categories: things over which I have some control and things over which I have none. The former consists of documentation, effectively planning my day/week, and some of the “taskier” elements of the job, such as locating resources. Most social workers are familiar with the latter as most of the emergent situations we face fall into this category. These situations can include mental health crises, medical emergencies, and (in the case of my hospice job) death visits. I have learned through trial and error that building efficiency in the first category frees me up to be more available for the myriad of concerns that arise on a daily basis. You can plan the anticipated structure of your day, but you cannot plan your emergencies.

Key to this process is the ability to use your wisdom and experience to triage situations and use professional discretion to re-prioritize on the fly. This comes with time spent in the field and usually involves many growing pains. It is crucial to map out your tasks and develop your own system for the more routine aspects of your job. You will then find it much easier to refine your plan as often as necessary in order to help you be as effective as possible.

Here’s a brief example of my own system:

I carry a caseload of patients that have to be seen a certain number of times per month. I also have a quota for the number of patient visits that I make during the week. I can control my scheduling of patient visits in order to meet these requirements. I can also schedule a little extra time each week for completing any unfinished paperwork. I can then pencil in any care plan meetings that I have to attend, which I typically know about in advance.

At the beginning of each month I make a chart of all my current patients, their monthly visit frequencies, and their type of residence (family home, assisted living, nursing home…). By spending an hour per month doing this I have created a visual with which to triage patient visits when emergencies come up and I have to shuffle my schedule. For instance, it is much easier to reschedule my patients that live in nursing facilities because they are pretty much always available for a visit. My home patients, however, may be counting on me to show up at a very specific time as they may not be at home otherwise. This system allows me to make sure that I get in my visits for the week/month with minimal disruption to my patients and their families. It also frees me up in case I have to meet with a new family to sign up a patient or to provide education regarding hospice services.

By planning my known duties, I free myself up for the “everyday life” occurrences that my patients/families experience and with which they require professional assistance.

Remember–Spending more time on the first category does not make you more effective at those tasks!! On the contrary, spending less time more effectively on the “taskier” elements of your job will free you up to give more attention and presence to the things that require more emotional energy. Work smarter, not harder, on your routine tasks.

You cannot plan a crisis, but you can learn to structure your time in a way that makes you more available and prepared when one should arise.