Out of Boundaries

“Look at me! Look at me!” a voice cried out to Sarah, the homeless shelter social worker, as she crossed the street, coming to work early that morning. Ricky, a child-sized man, wore a puffy white chef’s hat and hung on the back of a bakery delivery truck. That explained his recent gifts of baguettes for the soup kitchen. He waved wildly, and she called back, “Hold on!”

Ricky’s boundless energy was easily explained by his untreated hyperactivity, his sporadically treated bipolar disorder, and his crack cocaine abuse. When someone has both a mental health diagnosis and a substance abuse disorder, they’re identified as having a “dual diagnosis.” This label was coined in the 1980s, but mental health practitioners and substance abuse treatment providers still treated such clients as hot potatoes until the 1990s, when specialized programs were finally created and funded to treat both concurrently. Homeless individuals, often dually diagnosed, shared long histories of inadequate treatment.

Ironically, rookie social workers like Sarah often held positions working directly with the toughest populations. They were the foot soldiers of the profession until they earned their stripes, or left for easier jobs with better salaries. Ricky had been automatically added to Sarah’s caseload as her job was to assist any shelter resident requiring mental health services. He did not need to apply for her assistance, and she could not refuse to provide help.

On the other hand, the dual diagnosis treatment centers could and did refuse Ricky. They cited his triple or quadruple diagnoses of mental illness, substance dependence, intellectual disability, and hearing impairment. He was too disruptive, virtually illiterate, and, having been raised in a series of foster homes, had no family participation.

Despite these limitations, during the hypomanic phases of his bipolar disorder, he seemed to be protected by magic. Like the fictional characters Forrest Gump from the movie of the same name and Kramer from the Seinfeld sitcom, Ricky coasted through life, narrowly missing disasters and falling into unique and occasionally fortunate circumstances.

Sarah shook her head, seeing his picture in the city newspaper, which quoted him. A naïve or unscrupulous reporter interviewed Ricky after he was caught stealing baby formula. Willingly or confused, he played along with the reporter’s manufactured story of his desperation to feed his nonexistent baby. In truth, the formula had been intended for drug dealers to cut their cocaine. The police let Ricky go with another warning, dropping him off at the shelter, happy to be free of this problematic detainee. Ricky jumped out of the squad car, half a donut hanging out of his mouth, and waved goodbye without learning a thing.

Later came the tailspin.

“Help Sarah! You have to help me!” Ricky rushed in, yelling too loudly - hearing aids lost again. The wolves were waiting at the door. His money was long gone, and dealers threatened outside the shelter. Maybe he had been robbed, or smoked the crack he was supposed to sell. At times like these, Ricky might feign suicidal ideation to get hospitalized and off the streets.

Other times, the demons came from within; he now needed the stabilization medication he’d evaded when flying high on his more intense hypermania. His depressive mood swooped back in, combined with crack withdrawal, and slammed him down to earth. Then his suicidality was acute and genuine. Some days, he sought protection from both external and internal forces. Nonetheless, the hospital, like the police station, never held Ricky long enough for him to stabilize.

Sarah tried to outwit these cyclical crises by providing reminders and bus tokens for psychiatric appointments. It worked a fraction of the time. More than once, though, Ricky called her from across town, or farther away in an adjacent city, at the last minute, claiming to have no way to get to his doctor. Being an eager neophyte, she dropped everything several times to transport him to his appointment. Her objective was to ensure his consistent psychiatric care, but she soon realized Ricky was more interested in the ride.

She arrived back at the shelter and surveyed the collateral damage: resentful clients with needs unaddressed, phone calls not returned, and tasks not completed. Perhaps it was obvious from the objective outside, but only after coming down from the Ricky tornado did Sarah see how far she’d been pulled off track.

The importance of setting boundaries came into sharper focus that night when she left to go home and spotted Ricky in her rearview mirror trying to follow her car on a rickety and probably stolen bicycle. He looked frantic, like a child trying to find his mother.

Sarah cautioned Ricky that her help would no longer include providing last-minute rides. Ricky told his psychiatrist, who called her later in a huff.

“As his social worker, I expect you will guarantee his attendance at all hospital appointments. I don’t have the time in my schedule to waste,” the psychiatrist barked.

Her nervous supervisor weighed in, invested in maintaining the agency’s relationship with the hospital, which acted as if the mental health treatment for her homeless clients was their charitable act, despite being fully compensated by Medicare and Medicaid.

Sarah wondered, “How have I become solely responsible for this man-sized child?”

And then it clicked; she wasn’t. She reminded herself that she was Ricky’s social worker and not his lost mother nor his security detail. She couldn’t single-handedly act as society’s safety net.

Next, she took a deep breath and called the haughty hospital psychiatrist to clarify that, “I am Ricky’s social worker, not a taxi cab service.” The doctor wasn’t pleased, but he backed down. More bark than bite.

Then Sarah informed her anxious boss of the limits she set with the psychiatrist, simultaneously establishing her ground with her employer and earning her first stripes.

Maybe Ricky learned something, too? Only time would tell.