W OR K I N G W IT H mentally ill C LI E N TS 38 myevt.com exceptional veterinary team March/April 2012
Corissa C. Lotta, PhD, and Stacie L. Fishell, MA Peer Reviewed March/April 2012 exceptional veterinary team myevt.com 39
Working with clients who have mental health concerns is probably one of the challenges you didn t anticipate when choosing a career as a veterinary health professional. It can often feel like a daunting, even overwhelming, task to deal with people who have issues ranging from situational distress to long-term mental health diagnoses. Successful communication and boundary setting is a continuous process with all clients and will be unique to your career, practice, and setting. In addition, each interaction you have with clients creates, reinforces, or readjusts boundaries. The crux of successful communication, regardless of where someone falls on the spectrum of mental health, is within the relationship. Response = Intuition + Awareness + Skills It is important to recognize that stress and anxiety (such as when clients are concerned about their pet or there is a crisis situation) can bring out the worst in all of us. Remembering this can help you find a place of empathy when working with clients who seem to be struggling emotionally or mentally. Being able to respond compassionately is key to establishing and maintaining professional relationships and boundaries with all clients, particularly those with mental health concerns. Unlike reacting, which refers to an intuitive and instinctual response to a situation, response reflects intuition, awareness, and skills. For the purposes of this article, intuition refers to that which you know without knowing how you know; awareness refers to a deeper understanding of why/what something means through integration of further data; and skill refers to intentional application of knowledge and techniques for a particular purpose. An effective response when working with clients with mental health concerns requires an integrated engagement of all 3 domains. Responding to Clients with Mental Health Concerns Table 1 (pages 44-45) explains how to engage intuition, awareness, and skill before, during, and after a potentially distressful or critical client interaction to improve your ability to respond in a compassionate and constructive manner while maintaining positive boundaries. While there may be a tendency to focus solely on the actual event, attending to preparation and follow up will facilitate successful communication strategies for all involved. Before Several considerations regarding working with clients with mental health issues necessitate systematic and individual preparation. You may identify clients to whom you have an intuitive gut response to based on previous interactions that may help you and your team identify and prepare for potentially challenging situations. Your awareness may increase as you review a client s history, understand your own personal triggers, and gather information on the presenting concerns. In addition, establishing clear policies and procedures on how to address critical client interactions will allow your entire team to manage situations as they arise. These procedures can include steps for contacting local emergency services, compiling a list of mental health referral sources, and using role-play techniques to practice interactions. 40 myevt.com exceptional veterinary team March/April 2012
During In the midst of a difficult interaction with a client who is distressed and/or has mental health concerns, you are likely to experience myriad responses. It can be difficult to engage with clients who you perceive as responding with more emotion than the particular situation warrants. Managing the patient, your client relationship, and your own professional persona is uniquely stressful in challenging situations. Your first sense that something is off is likely to be an intuitive process. Pay attention to the autonomic body responses of yourself and your client. Are you experiencing (or do you notice your client experiencing) increased respiration, sweating, or arousal? This instinctual response is likely to trigger a flight, fight, or freeze response for both you and your client. As your awareness increases while you engage in the interaction, pay attention to your intuitive responses and try to understand why you feel compelled to act in a specific way. When experiencing a fight response, you may find yourself raising your voice, becoming angry, or posturing aggressively. It is essential, therefore, to pay attention to unusual affect, nonverbal behavior, and verbal expressions so you can emotionally step back from the situation, understand your instinct, think about how you want to engage differently, and implement further skills. Notice how you and your client may each be feeling, taking note of unusual nonverbal behaviors (body movements, eye contact, aggressive posturing). Pay attention to changes in speech pattern, volume, and rate or changes in the way your client is interacting with his or her pet. Unusual verbal expressions, such as excessively repeating statements, direct or veiled threats, and extreme language may indicate increased distress. Understanding these intuitive responses and being aware of yourself, your client, and the situation will allow you to employ skills to engage the client compassionately and effectively. FIRST, determine whether this is a situation you can handle on your own. If not, arrange for a colleague to join you or, if you are concerned for the safety of others or the client (see Suicidality in Table 1. pages 44-45), immediately follow your practice s protocol for emergency situations. If the situation is manageable without outside intervention: Remember that you are a trained observer of animal behavior; those skills are transferable and applicable to working with people. Recognize that your emotions and behavior will be read and interpreted by the client. Be calm, compassionate, and confident. Speak clearly and directly; try to remember that maintaining strict boundaries may feel patronizing in some instances but may provide a much-needed gift of structure to a client experiencing emotional or mental distress. Compassionate and caring directness may help a client stabilize her/himself, allowing both of you to provide the best care for the animal. March/April 2012 exceptional veterinary team myevt.com 41
After Once the client situation has been handled, it is important to discuss the experience with your colleagues. First, express your feelings, release physical tension, and let yourself simply react to the situation. Once you have had the opportunity to express your intuitive responses, continue to increase your awareness through dialogue and thoughts about how you handled the situation, how you responded to the client, and what was effective or ineffective in your handling of the situation. Elicit feedback and address your strengths and limitations so you can continue to improve your skills in this area. Finally, identify further resources for the client and continue to firmly maintain the boundaries of what you are able to provide to the client in regard to personal support, patient care, and a future working relationship. A comprehensive and intentional response when working with a client in distress requires preparation, an ability to integrate intuition, awareness, skills, and thoughtful follow-up. Summary A comprehensive and intentional response when working with a client in distress requires preparation, an ability to integrate intuition, awareness, skill, and thoughtful follow-up. Remember that the relationship is central to your work with all clients whether or not they have mental health concerns and that positive boundaries are established and maintained throughout every client contact. Through compassionate use of skills in responding to clients, you can most effectively serve the health and wellbeing of both clients and their pets. EVT 42 myevt.com exceptional veterinary team March/April 2012
Table 1. Applying Intuition, Awareness, and Skill to Working with Mentally Ill or Distressed Clients Intuition ( Knowing without knowing why or what it means) Awareness (Understanding why/what it means; gathering more data to understand the situation) Skill (Intentional application of knowledge and techniques for a particular purpose) Before Pay attention to: Gut reactions/feelings about particular clients in previous interactions. ( What do you know without knowing why you know? ) Consider: Your personal history, strengths, and limitations. ( What are my triggers? ) Client s history, strengths, and limitations. Are you aware of a mental health diagnosis? (depression, anxiety, schizophrenia, complicated grieving, etc). ( What might be challenging for/with this client? ) Presenting concerns. ( Is this a situation that might trigger the client? ) Develop and practice policies and procedures for critical client interactions: Phone numbers of emergency services (eg, local police, 911). List of local mental health resources. Local and national suicide hotline numbers (National Suicide Prevention Hotline: 800-273-8255). During Pay attention to: Autonomic body responses of you and your client (increased respiration, increased heart rate, flushing). A sense that the interaction feels unpredictable or confusing. ( Something feels off. I can t follow what the client is thinking or saying. The client can t seem to follow what I m saying. ) What do you notice about: Self: Fight, flight, freeze. ( I m reacting. ) Client: Fight, flight, freeze. ( The client seems to be reacting. ) Is what you notice about the client out of proportion to your understanding of the situation in the following areas: Unusual affect: Angry, sad, agitated, despondent, distressed, distracted, excitable. Unusual nonverbal behaviors: Body movements, eye contact, energy level (high or low), aggressive or closed posturing, speech rate/volume/patterns, change in how he/she is interacting with pet. Unusual verbal expression: Repetitive or confused speech, extreme language ( always, never, have to, can t, won t ), direct or veiled threats ( I can t handle this. I can t go on without Fluffy. You ll be sorry if you don t fix this. This is your fault. I can t trust you you re just like everyone else. ). Based on above observations: There is something else going on that I don t understand. I need to intervene in a different way. Ask yourself, Is this a situation that I can continue to manage on my own? If no: Step out of the room. Inform colleagues of concerns, and/or bring a colleague into the room. If safety is a concern, engage emergency response plan. If yes, attend to your own: Affect Remain calm. Find a place of compassion for difficulty of client experience. Engage same confidence you would utilize with an animal in crisis. Nonverbal behaviors Adopt a confident/assertive (but not aggressive) posture. Maintain steady eye contact. Keep speech rate slow/steady/moderate volume. Use soothing gestures and vocal tone with patient. Verbal expression Use words of empathy and care, repeating as necessary. ( I know how much you care about Fluffy. This is a lot of information. How can I help you better understand what is happening and what we need to do for Fluffy? ) Set and hold clear boundaries (repeat as necessary). 44 myevt.com exceptional veterinary team March/April 2012
After Reflect on all parts of the interaction. ( What was effective? Ineffective? ) Solicit feedback from others involved. Express emotions, release physical tension, react to situation ( Here s what happened ) Share your observations ( Here s what I noticed ) Incorporate any additional data that shed light on the situation. ( Now that I know her husband died of cancer, it makes more sense why she reacted that way. ) Inform/remind client of your expectation for his or her behavior. ( I need you to lower your voice and stop swearing at my staff. I can tell that you are very upset right now and it s hard for you to talk with me. I m going to step out for a few moments and give you a chance to compose yourself. When I come back in we can try again to discuss Fluffy s care. ) Use If/then statements. ( If you cannot compose yourself enough to discuss Fluffy s care today, then you will need to take her home and I will call you tomorrow. If you cannot be respectful to me and my staff, then I will have to ask you to leave. If you choose not to leave on your own, then we will have you escorted from the premises. ) Suicidality Approach directly and honestly. ( When I hear you saying that you don t know if you can go on if we euthanize Fluffy, it makes me concerned about your safety. Are you thinking about hurting yourself? ) If client answers no, respond with. I m glad to hear that. I know this can be hard, so I wanted to be sure that you have the support you need if you were thinking about harming yourself in any way. If client is unsure or answers yes, ask if there is someone you can call. If not, follow your emergency plan (eg, call 911). ( If there isn t anyone we can call, then I am going to call 911. I understand this may upset you, but I need to make sure you are safe. ) Plan next steps Make sure client understands and agrees to the treatment plan for the pet. If you are uncertain of the client s capacity to comprehend the information, ask if there is another person with whom you can talk about treatment. Make sure the treatment plan is given verbally and in a written format. Establish a time for a follow-up call. ( Perhaps now isn t the best time to discuss Fluffy s treatment. I will call you tomorrow after you have had a chance to absorb more of the information and think of any questions you want to ask me. ) Based on analysis of situation: How do I further hone and intentionally use my strengths? How do I address and remediate my limitations? As needed, continue to gently, but firmly, set boundaries ( As we discussed when you were here, I cannot discuss Fluffy s care with you when you are yelling at me. ) As needed, guide the client to resources/support beyond you. ( It seems that what you need at this time is beyond my training and expertise. But I have some resources that might help you get the support you need. ) March/April 2012 exceptional veterinary team myevt.com 45