During the first year of my social work graduate program, I interned at a comprehensive care clinic at a New York City-area hospital. The primary population at the time was adults living with HIV and AIDS. The social work team was small- only four social workers on the team- and I shared a caseload with my field placement supervisor. The social workers would see clients at the clinic but also rotate to the inpatient floor of the hospital, so whenever it was my supervisor’s time to go to inpatient, I’d tag along.

One day, she asked for me to do a quick intake assessment for one of her clients who had been admitted on the inpatient floor. He was a middle-aged man with the initials “PM”, who was very pleasant and invited me to have a seat in one of the chairs in his room. One of the questions was confirming his AIDS status. He confirmed it, but quickly told me that no one else knew of his diagnosis, including his family.

I saw PM a few months later back in inpatient. This time, he looked completely different. He’d lost a lot of weight and his face was sunken. He was very weak, and couldn’t speak. In his room, I was met by his brother who seemed agitated because he wasn’t informed why his brother had been admitted. Before seeing PM, I looked at his clinic chart to discover that he’d been diagnosed with Epidemic (AIDS-associated) Kaposi sarcoma, an aggressive form of cancer. While asking questions from the intake assessment (after his brother stepped out of the room), PM answered with paper and pen. Before leaving, I asked PM if there’s anything he wanted me to tell my supervisor. He asked about the likelihood of him being discharged to go home.

A week later, I received a notification in the staff’s client appointment system that PM had died. I looked in his chart again to see an updated medical note from his clinic medical provider. The provider had recommended to PM’s brother and mother that PM should be discharged for hospice care. When asked why, the provider had to disclose PM’s AIDS status to his family.

Soon after PM’s death, my supervisor and I went back to inpatient, this time as witnesses for a young woman signing legal documentation to assign custody of her young sons to a relative. She died soon after. My supervisor asked if I wanted to debrief with her about PM’s and the young woman’s deaths, and I remember telling her that I was fine but would speak to her about it if I needed to.

I went from experiencing these deaths as a student to experiencing the deaths of several clients while working at my old agency after graduating. One client died by suicide, one was found dead in her apartment under suspicious circumstances but was later determined to be health related, one died via a drug overdose, and there are others who died but so much time as passed that I can’t remember their causes of death. On top of this, my staff would get routine emails informing us of clients who have died in other departments, along with the deaths of some staff members.

But the death that impacted me most was “LB”. He was middle-aged man whom I’d met around 2 years after joining my agency. When my supervisor introduced me to him in his office, LB was sitting across from my supervisor’s desk, crying as he wanted to sign up for services plus being spooked that he’d had 3 heart attacks in that month alone.

LB quickly became one of my favorite clients, where I’d do frequent home visits with him and I managed to get him a receptionist job at the agency location. The last time I saw LB was in April 2015 when he stopped by to see me for an update on a medical visit he’d just left. After that, all of my calls and letters either went unanswered or returned to sender. I managed to get in contact with LB’s mother that August, where she disclosed that LB died earlier in May from a heart attack. I told my supervisor and gave her his case closure documentation, and went about the rest of my day. When I got home, I sat on my bed and cried.

At the time, I thought I cried specifically for LB. In hindsight, I cried not only LB, but all the clients that died before him. I never fully gave myself the space to process each death (particularly the deaths that occurred when I was a student) and I think in some ways I’d become desensitized to hearing about the deaths as I transitioned from student to professional.

Have a question you’d like to be featured? Let me know.

Back when I doing direct practice client work, I had a client who was undergoing a housing issue. The issue was at the fault of the client, and the client asked for assistance in eviction prevention. 

One day while interacting with this client, the client blamed me for not doing enough to help fix the situation. I could feel the anger growing from within. When the client told me, “You don’t know what I’m going through,” I wanted so badly to remind the client that the situation was occurring because of the client’s own doing. More so, what I really wanted to say was…

“…And you don’t know what I’m going through!”

In addition to personal matters, I was dealing with the death of one of my favorite clients and the suicide of another client, of which I was asked for documentation that proved I did as much as I could to prevent the situation. I was on edge, to say the least, but luckily for the client, the situation worked itself out and the client was able to remain housed.

I’ve gotten a few emails from social workers and students over the few past months asking me share the aspects of social work I don’t like, specifically from a direct practice perspective, including dealing with difficult clients and how to stop caring about clients once the work day is over. There’s plenty of professional advice on this the you can do a quick Google search on.

But to answer the questions, my short answer is this: Establishing boundaries isn’t enough, empathy is everything until it isn’t, leaving your clients problems at the office is not easy, and clinical/direct practice social work ain’t for everybody. 

You’ll hear of social workers leaving the field for a variety of reasons, but for me the answer was pivoting to another aspect of social work that better suited me. 

As a disclaimer: Is what I’m about to share the case for all direct practice social workers and case managers? Not at all. In fact, everything you learn in clinical studies and practice—engagement, assessment, planning, implementation, evaluation, termination, and follow-up—translates to most social work positions, and is the model I use with my consulting clients. So I did learn a thing or two while working in direct practice. 

When I landed my case management position 3 months after graduation from my masters program, I was just happy to be employed. When I first started, I had a caseload of around 25-30 clients. By the time I left nearly 6 years later, I had close to 90 clients. 

That may not seem like a lot, but having to engage with 90 clients (and their providers and emergency contacts) on a monthly basis was taxing. It did a literal number on my self care, self esteem, and my desire to remain in the this work. 

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