Mental Health

Anxiety

Right from the first day Claire was highly organised, well manned and quiet. I found it a bit odd that she wore long sleeves and jumper to work even in the middle of summer but then the air conditioner made the ward cold. Early in her placement she was shadowing me and took notes while I spoke to patients. It took quite a few weeks of coaxing for her to do the assessments on her own. In response to her fear I broke the process down and took her through the assessment step by step and repeated that until she felt comfortable. She did undertake two assessments and her reports were of a very high standard. Yet her engagement with the patients was clinical and almost cold. Then I arranged for her to attend an out patients clinic with another worker, I thought she would like the experience. Her reaction was fearful and anxious to the point that she said she could not do the clinic as she was feeling sick and needed to go home.

In supervision the next day I notice she had her arms bandaged under her long sleeve shirt. Her response was that it was just a little accident nothing to worry about. Once more I asked her if she would like me to organise a clinic experience for her. Again she became fearful and sick and began to panic. I came to realise that Claire was suffering from anxiety. At the end of the day when everything was calm I took the opportunity to raise my concerns about her anxiety.

I listened non-judgementally as she told me of how she did not manage well in new environments and she cut herself as a way of releasing the stress build up. She told me how she had taken weeks to prepare for placement. She developed a ritual of chanting to herself that everything would be ok and writing affirming messages all over her flat. She was, up until now, managing the placement because it was organised and repetitive. She liked the way I spent time helping her work up to doing the assessments. She told me she desperately wanted to find another way of coping but didn’t know where to begin. She was fearful that I would ask her to leave placement. Instead we talked what supports, information or professional help would be useful. She agreed for us to both talk to our University Liaison person about the impact on her placement hours, her learning plan, and getting support from a counsellor.

From there we agreed that we would explore her anxiety and self-harm not as a problem but as an opportunity to learn more about herself, explore positive coping strategies that would allow her to develop a positive professional future.

Key Considerations

  • My role as supervisor. Once I knew was she was crossing from being a student to a client, I had to consider what my role was as a social work educator.
  • My role as the senior social worker in the unit. Were there any policy or procedures I needed to implement to ensure the student and others’ safety?
  • Professional standards and University requirements. I had to ensure that the placement did not turn into a therapy session and that she continued to meet all necessary requirements.
  • Confidentiality and student autonomy. Negotiating with the student about who should know and why.

What went well?

  • I was surprised how calm I was. Claire is the first person I have known who uses self-harm as a strategy to deal with anxiety. Even though I was emotional I am proud that I stayed focused on her as a person in distress but also as a student with potential to learn and be a great social worker one day.
  • Building on that I didn’t see it as a problem but as an opportunity from which she could learn more about herself.
  • I was happy with the way I upheld confidentiality – it was Claire not myself who suggested we include our University Liaison person. Together we talked and came to the conclusion that really at this point no one else needs to know.
  • I’m glad that we had a structured supervision process. This had built the trust between us so we felt we could talk openly to each other. We used supervision to work out a strategy for the times she felt she was getting anxious and was not coping.
  • The link with the University was fantastic as they connected Claire with a counsellor from the Student Services at no cost.
  • I think the other thing that worked well was being clear about my role as a supervisor concerned about minimising the impact on her learning and professional identify. It would have been easy to slip in the role of a therapist or social worker or mother or saviour!

What didn’t’ go so well

  • Although I felt I did a good job it was my first encounter and so I think my response was a bit clunky.
  • I would have liked to have had prior knowledge of her anxiety. I am a bit disappointed that she didn’t tell me earlier.
  • There isn’t much room for flexibility in this hospital and placement context. I could organise some flexibility around the work but Claire still had to do the hours and demonstrate that she had the competency to meet the University standards.

What might you differently next time:

  • I think I did everything right in this situation but since then I have successfully lobbied for some changes to how we respond. We now have a
    - Draft policy and procedure that address possible organisational responses to mental health in staff and students.
    - Mental health awareness training has been offered to staff and students in a hope that it will increase awareness and positive response.
    - I have developed a proforma for a mental health action plan that can be used to work with students whose placements are impacted by mental health issues.
    - I think the biggest achievement is that we are openly discussing it in supervision and team meetings.

Becoming sick

Clayton presented at the pre placement interview as a passionate student with clear opinions and confidence. He was a qualified accountant and was now re-training into social work. I could see how he could fit into our inner city homeless support agency, however the trouble is that he doesn’t fit in. From the beginning he rubbed the other staff up the wrong way. He dominated discussion and spoke in a loud raised voice that some staff found intimidating. He appeared to have trouble accepting work directions from me. Although he verbally indicated that he understood and knew what to do, when I asked for an update, he would argue he was told to do another thing or nothing.

I began to dread supervision time with him as he did not take feedback well and I also felt at times intimidated at his aggressive stance and behaviour. For my own protection I would leave the door open when alone with him. This is not the case when he is working with clients; interestingly his interaction with the clients is very positive. He is kind and respectful and he has proved to be very good at working out what they need and how to get it. When it comes to doing tasks or following procedures to do with the clients he is timely and accurate in his execution but the same cannot be said for agency policy and procedures that he appears to regard as an annoyance. I contacted my University liaison person and filled her in with her concerns.

Over the next few weeks two joint meetings were held to discuss the concerns. The first ended badly with Clayton saying he felt victimised and confused as he was doing everything he could but that I was the problem. In the second meeting I indicated that the placement would need to be terminated unless Clayton took responsibility and worked on his attitude. Clayton was highly distressed became very quiet and handed me a business card with the name of his physical therapist on it.

The therapist had been working with him on pain management (spinal injury) following a traumatic event where Clayton had been mugged, robbed and brutally beaten 12 months ago. The therapist was aware and concerned with Clayton’s deterioration and depression and situation and offered on a number of occasions to give him a referral to counselling but as an ex-army man who had seen overseas action, he told me that he did not see the point in Counselling as he could handle it. He had not disclosed this to the University about the injuries or his depression because he did not see how it would impact on placement as it his academic work had not suffered.

Given this addition information the decision was made that Clayton continued with placement but with reduced hours over a longer period as a way of coping with the stress and tension; his work allocation, performance and supervision was tightly structured with clear and reportable outcomes and milestones. I requested and received support and mentorship from the University. Clayton and the University arranged for him to be assessed for Counselling and also tested for brain injury. The assessment came back as Post Traumatic Stress Syndrome sustained on duty and further compromised by the mugging and stress. Clayton eventually passed placement. I was happy with the response as a supervisor but felt I was traumatised by the event and questions the wisdom of focusing so many resources to prop up a student like Clayton who will struggle to practice unless he manages his health.

Key considerations:

  • Role as supervisor
  • Agency policy and procedures and adherence to
  • Duty of care to self and others including clients
  • Work place health and safety given the potential for violence.
  • Confidentiality
  • Student autonomy and rights to disclose
  • Resource allocation

What went well?

  • My commitment to supervision even when it was difficult and confronting
  • I acted early involving the University as soon as she felt compromised and concerned.
  • Observing the differences between client engagement and agency engagement by the student, showed that there were aspects of the placement where he excelled and other areas (e.g. agency practice) where he needed strategies in place to allow him to cope.
  • Flexibility to renegotiating placement to benefit of the student and agency.
  • The priority response from the University.

What didn’t go well?

  • The lack of agency policy and procedures to guide response
  • The pre-placement meeting highlighted concerns but these were not considered or questioned until placement had started.
  • The ethical issue of how much support to provide struggling students.
  • As a supervisor, my sense of guilt that I was so confronting when I could have been compassionate. Then guilt for thinking that the student really shouldn’t be in this profession.

What might you do differently next time?

  • Redesign the pre-placement interview to drill deeper into the reasons and expectations of the students.
  • Structure supervision in the early period in a way that sets the expectation of reflection as well as accountability.
  • Be clear with the student about expectations and boundaries. Have clear mechanisms that allow you as a supervisor to raise issues even when they are bitterly contested.
  • Be kind and respectful even if the student is driving me crazy.