KAREN
I have been a social worker with the VA going on twelve years now. I’m actually from Florida. I went back to school when my kids were little in my early thirties and got a Masters in Social Work. I was hired by the VA straight out of school. I came to MHICM kind of round about. First, I worked oncology for a few years, homecare for a year and then substance abuse. I came to the MHICM program just about six years ago. This has been, by far, my favorite area.

One of the things I like about MHICM is that you see results. You get to work closely with the same folks over time. You have the opportunity to see incredible progress and change in quality of life and I think that is probably the most rewarding thing about it. You’re part of a family, so to speak. There’s no way that you could develop these relationships in a hospital setting with veterans coming in and out. I’ve actually known quite a few of the patients for the full six years and that’s the benefit of assertive community treatment. Although there are VA pressures to discharge, the model is that you keep the patients forever unless they move or have a celestial discharge from the program.

Everyday really is very different. Some days I might visit veterans in one particular area. Generally, I’ll do fun things with them--like maybe go out to lunch, or go to Star Bucks and have coffee. These opportunities are informal ways to check in with them and see how they’re doing with symptoms. Sometimes I help them with things that you and I take for granted, like shopping and banking. The case managers help them become more independent in those things. We help them with medical appointments; we might bring them in to see a provider and stay with them if they need that for comfort. Helping with cleaning, teaching about activities of daily living and teaching about hygiene can also be part of a typical day.

The socialization aspect is probably one of the most important things we do, because a lot of the schizophrenic patients may have the negative symptoms predominate. They really don’t get out there and do things, and they don’t make friends and they don’t interact. Part of what we do is bring them together in two ways. We do a lot informally—just spur of the moment driving around or doing a coffee outing with a veteran. We’ll decide to include another veteran or two and you got a spontaneous group where they have the opportunity to get to know each other in a non-threatening setting. There are also formal groups set-up. These include a weekly support group, a spirituality group, a recreation group and a monthly lunch outing. Those are the main ways that we encourage socialization.

In the support group, we have talked a lot about the stigma that the veterans experience as a result of their illness. That can actually have ramifications as far as their treatment in a medical setting. If someone shows up to the ER or to their primary doctor with a primary diagnosis of schizophrenia, it’s actually not uncommon for them not to be taken very seriously. That’s sometimes a barrier in terms of their care. Stigma is certainly something that they encounter every day. That’s one challenge—helping them deal with these things. I think one of the things we do to help reduce the burden of stigma the veterans experience is try to educate other people as well---family members, other care providers.

One of the challenges as case manager is you never know what you’re going to find. These veterans can change from day to day. You really have to stay on your toes, you have to stay flexible, and you can’t really have a set schedule. Our job is to watch for changes in their psychiatric condition. We are creative and find ways to deal with the psychiatric issues as they come up to prevent re-hospitalization. That, I think is the biggest challenge but it’s also what keeps it fun.

It’s important to develop a comfort level with folks whose presentation can be unsettling at first. It’s equally important to provide a comfortable environment. That really helps with folks who are having issues of their own and are afraid of their world. For a lot of them the world is a very scary place and there’s just so much coming in that they have a hard time filtering it out. They need a caring environment and they need to feel safe.