The Reward Is Not In The Pay

As with any helping profession, working in mental health beats the crap out of you emotionally. It can be difficult to maintain a positive attitude and instill hope in your clientele when you listen to severe trauma and stressed out individuals all day long. Throw in the fact of maintaining administrative duties on a supervisor level too. The entire week feels like one long Monday morning. However, my work provides seldom reminders of why I continue with my chosen field.

At the tail end of 2017, I received one of my most interesting referrals to date. It was for a 21-year-old male who was recently hospitalized for psychosis. This young man was suffering from a rare form of schizophrenia that resulted in severe catatonia. It happened following stress related to school and several family members passing away, including his father.

Reading over his referral was fascinating. Although extremely rare, catatonia can occur from depression and schizophrenia spectrum disorders. In my ten years in the field, I had only worked with three or four such cases. He was preparing to be discharged from the hospital and into my care.

Going out to his home for the first session, I honestly did not know what to expect. Catatonia affects individuals in a variety of ways. Sometimes the individual makes a full recovery with a mere improvement in mood. Others experience mild improvement but still possess slow movements or slurred speech.

I pulled up to small house sitting on an intersection in a quaint suburban neighborhood tucked away from the main roads. His mother answered the door and said “Hello!” emphatically. However, this was the extent of what she could say in English. Not only would I be dealing with rare symptoms but now there was a language barrier to overcome. The family predominantly spoke Vietnamese.

I walked into the living room and sat down on the couch. Across from me sat a young man. He was about five and a half feet tall with short black hair and olive skin. He appeared to be in relatively good shape. Almost immediately though, something did not feel quite right. He was as stiff as a board. As I sat down and introduced myself, his mother pulled out a small table and brought me a bottle of water. He could not move his head to face me. His eyes shifted slightly to the right in an attempt to make eye contact. He could not keep his eyes on me for long as his eyes teared up. He could not blink. His mother wiped the tears away from his eyes.

By far, this was the worst case of catatonia I had ever seen. I spoke to his mom and him through a phone-based interpreter. I tried asking him a few questions to get to know him, but my questions were met with blank stares. You could tell he wanted to say something but he could not push out the words. This was a combination of the catatonia and another symptom called “thought blocking.” This happens often with cognitive deficits associated with psychotic disorders. The individual struggles to articulate their thoughts and may even stop what they are saying mid-sentence. This young man could only answer “yes” or “no.” Thankfully, his mom was able to provide a good amount of information. She explained the extent of his symptoms. He could not dress himself. His food needed to be blended into a smoothie and fed to him through a straw. He could not even go to the bathroom by himself.

It broke my heart to see a kid who was a fully functioning adult who was working for his family and going to school full-time reduced to this. There was no more independence. He relied on his loved ones for everything.

Over the next three months, his condition worsened. My team and I tried everything including new medications, therapy, and going for walks with him. To no avail, it got to the point where he required assistance walking down the hallway with his mom on one side and a staff member on the other. He would regularly fall over because one of his legs would just give out. We were left with no other choice really except to try electroconvulsive therapy (ECT).

When individuals think of ECT or “shock therapy,” they often think of the old school asylums. Today’s ECT is a shadow of its predecessor. The biggest side effects nowadays is short-term memory loss. For this kid, it was a small price to pay if he was to have any quality of life. Near the end of February 2018, I went with his mom and him to an evaluation with the lead psychiatrist. I informed the psychiatrist right away of the obstacles I first experienced, and he handled it beautifully. He agreed that ECT seemed to be the way to go, but that it would benefit my client if he were to be hospitalized for three to four weeks at the start of his treatments.

We meandered down the hall to help him get an EKG and to meet with the anesthesiologist. He would have to go under for his ECT treatments. He passed the EKG with no issues. When we got to the anesthesiologist, we ran into a huge problem. My client could barely move his jaw enough for the anesthesia to work. I panicked. This kid was going to have to suffer because of the very symptoms that got him here. The anesthesiologist consulted with the psychiatrist and her colleagues. Luckily, they decided to move forward with the procedure.

A week or so later, I put in my resignation following a controversial change in leadership. I started to inform my clients about it the following week. My client’s mother was not happy. She was worried about who would be helping her son after I left. I informed her that it would be my team members who were already well aware of her son’s condition and situation. I had one last task to complete with him before I left.

My last week in that position I accompanied my client and his mom to the hospital where the ECT treatments would begin. He would receive them three days a week and likely be in the hospital for three to four weeks to monitor his progress. I woke up around six that morning. It was bittersweet to see him getting the help he needed. At the time, this warm hand off was likely the last time I would see this young man. It hurt to know that I might never know his progress, his improvement, and overall quality of life. I wished him the best.


Fast forward six months. I am working around thirty hours a week as an in-home counselor for children and adolescents. The weird hours and complexity of the cases was pissing me off. I did not want to keep this up full-time and was looking to get back to more of a traditional counseling role. Fate answered my call. A former colleague informed me that the management that caused me to leave my former position was transferring to a different department. This meant that her position would be opening up. Three interviews later, I was back.

During my six-month absence, one client that regularly crossed my mind was the aforementioned young man. When I came back, it turned out he was still in the program. The team member he was working was preparing to transition out as well. I decided to pick up where I left off.

I showed up once more to the quaint neighborhood I was oh so familiar with. I pulled up to the same corner house and called them to let them know I was there. Out the front door stepped his mom holding the screen door. Then came the young man. He walking on his own. His posture was upright. Nobody needed to spot him. He was doing it all on his own. They got in the car, as I got ready to take him for blood work. I expressed my amazement to the client and reminisced about the last time I saw him. The client did not remember me, which I was not surprised about given the memory loss associated with ECT. I re-introduced myself and smiled in happiness. He still struggled with speech at times. His lips quivered, and his facial expressions were withdrawn. Overall though, he did a 180 from the last time I saw him.

Since I last saw him, he continued to undergo ECT treatments, which were now down to once every two to three weeks. He was also on a new medication called Clozaril. I was taking him to get blood work to check his white blood count from this medication.

Astoundingly, he continued to make improvements over the next few months. His memory came back. He began cracking jokes on his own and laughing. I could ask him open-ended questions with little to no prompting. Even with the progress, I hoped he did not become stagnant. As a counselor, I push my clients and always help them to look forward to the next step.

In his case, I took the client and his mom to a local program where he could obtain a paid internship for web/graphic design. I have been in the process of obtaining accessible transportation for him. We even looked over his college courses and discussed where he might want to go in the fall. All these steps were amazing, but our conversations and his goals felt materialistic and shallow. Rarely did I ever get my client to open up to me emotionally. Whenever I asked him how things were going, he normally responded with, “It has been okay” or “Everything is normal.” This week’s session was anything but normal.

I showed up around noon and received my usual warm welcome from his mom. He was sitting on the couch waiting for me. This was the first time I saw this client in three weeks due to scheduling conflicts and being out sick. I did not come in with a specific agenda to discuss. I just wanted to see how he was doing since he primarily worked with my other team member since our last session.

He first “feeling excited” to go back to work. I was taken aback. That was the first time I ever heard him express a feeling other than “okay.” The week prior he went to an assessment for accessible transportation for those with disabilities. He would likely receive notice in the coming weeks of the results. He appeared genuinely excited that this was the closest he had been to any form of independence in nearly two years. His next words were, “I’m tired of being stuck in the house.” Now he was expressing his boredom and frustration. I tried not to be speechless, so I smiled and continued the conversation.

Like I mentioned, I did not go into the session with an agenda. My intuition kicked in. I figured this might be a good opportunity to bring up his feelings surrounding other areas we never touched upon. “I was thinking on my way here today that we might be able to talk about your dad. You never told me what happened to him.” The only thing I knew was that his father passed away five years ago and that my client fell into a deep depression because of it. This information came from his mother and hospital records. I wanted to hear it from his mouth.

He showed me the picture of his dad that was up on the wall and began. He told me how his dad was at a party with family and friends. His mom and younger brother were on their way with his dad. Suddenly, his dad passed out on the way home. He unfortunately came out of it. He was unclear on the exact cause of death and thinks his mom did not tell him on purpose.

I just sat and listened. I could not believe he was going into detail about something so tragic. Every conversation up until was small talk. I felt connected to this kid for the first time in my year and a half of working with him. What came out of his mouth next blew me away. “Do you want to see pictures of his funeral? They are on my laptop.”

He went upstairs and brought down his laptop. There were hundreds of pictures of the ceremony and burial. There were several hundred people in the pictures who showed their respects to this wonderful man. I asked, “When was the last time you looked at these?”

“A few weeks ago.”

“How come you look at these?”

“To help me remember.” Due to a combination of his symptoms and the side effects of his ECT, his memory was greatly affected. He utilized these pictures to help himself grieve and remember his father.

“What do you remember about your dad?”

“He gave me what I needed and took care of me.”

“What do you think your dad would think of you today?”

“He watches over me. He just wants me to be successful and have a good future.”

This was the longest conversation I ever had with him about any single topic. It lasted nearly 45 minutes. I had tears of joy clogging up my eyelids. I held them back and thanked him for sharing with me.

I drove back to my office feeling all warm and tingly inside. I was in amazement. I could not believe what happened. It felt surreal.

As soon as I got back to the office, I shared the story with my prescriber who has worked with him just as long as I have. Her simple words summed it up, “That’s amazing.”

That session was a subtle reminder that my work pays off. I am making a difference in my clients’ lives. I am having an impact. It makes me feel like I made the right choice by coming into this field. It is moments like these that we hold onto and that remind us that the reward is not in the pay.

-The Caring Counselor

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