I have a part-time job as a case manager at a homeless shelter while I am gaining hours toward licensure.  I don’t know what to do when my clients don’t follow through on the referrals and other support I give them.  Since I’m not their therapist, I can’t talk to them as I do with my therapy clients to understand what’s getting in the way.

It is true that your relationships with clients as a case manager are different from the relationships you have as a therapist.  However, some of the interventions you use as a therapist are valuable in case management, and your clinical knowledge is a valuable tool for understanding the reasons for your clients’ lack of follow through.

Motivational Interviewing is a useful approach when clients show ambivalence about getting help or about changing aspects of their lives that are problematic (www.motivationalinterview.org).  Using this as the basis for your work helps you establish a collaborative relationship and puts the client at the center of the decision making about change.  Identifying and resolving ambivalence is a central feature.  Talking with the client in a way that is consistent with Motivational Interviewing may help you to shift from a position of responsibility to help the client use your referrals and support to a position of supporting the client to identify her/his goals and the steps s/he is ready to take.

Your experience as a therapist may also be helpful in understanding the basis for the client not following through with your referrals or suggestions.  You can develop a conceptualization of the client’s difficulties and strengths as you would do with a therapy client, based on the information you have about her/his history and diagnosis.  As a case manager, you are probably working with more limited information than you have in psychotherapy, but you may have enough information to make some inferences about the underlying reasons for the client’s lack of follow through.  For example, clients with a history of trauma may be sensitive to feeling coerced, clients who have a psychotic disorder diagnosis may misinterpret your suggestions or be confused about the information you give them, and clients who have lived on the streets for many years may need the sense of community and self-identity of homelessness to feel safe.

Another application of your clinical skill is in identifying the client’s interpersonal style with you as a way to understand her/his internal template for relationships.  This will help you develop ways to work with the client based on her/his assumptions and fears about relating to others.  For example, if you feel intimidated by the client you can infer that s/he organizes relationships around issues of power with one person holding power and the other being powerless.  This would indicate that interacting with the client in an authoritative but non-punitive way is likely to be more productive than either attempting to take charge or responding passively.  A statement reflecting this middle ground would be “I have some ideas that might be helpful to you, but it’s hard for me to sit here with you when you’re yelling at me.  Would you be willing to stop for a moment and see if any of these resources are relevant for you?”  Using your clinical skill in this way will result in subtle but important differences in how you talk with different clients and is likely to be more effective in helping the clients use the resources you have to offer.

I hope you are able to use these suggestions in bringing your clinical knowledge into case management work.  Please email me with comments, questions or suggestions for future blog topics.