by Robert Lanz, LCSW

(There a story that all beginning Buddhists learn and it goes like this: Two Buddhist monks are walking along a forest path and one of them falls into a very deep hole. The other monk looks down and sees his friend laying hopelessly at the bottom of the hole obviously injured and in pain. There is no way to get the injured monk out of the hole so the other monk immediately jumps in with him. Suffering alone, to a Buddhist, is the worst thing imaginable.  Sometimes you can’t do much about it, except to jump into the hole, too.)

Start where the client is.  Start where the client is.  That’s what they drummed into me during the two years I labored through graduate school.  It must have been considered a difficult concept, more than a student could grasp on his own, or they wouldn’t have made such a big deal of it.  I believed them.

Simply stated, “start where the client is”, means if you are going to get somebody to change—to get better in some cases, to adjust to being worse in others—you have to connect with them as they are at the moment.  It is extremely difficult to lead a patient somewhere if you are unable to clearly demonstrate that you understand where he or she already is, emotionally.

Coming to this understanding was often problematic, as the client might have been unaware of where he was, in a psychological sense, and he could have been using some basic psychological defense or some cultural dodge to keep his pain at a distance.  Or, he might have been smart enough or experienced enough to know that he would eventually get better, with or without intervention.  No matter, my job was to understand where the client was emotionally, to use my professional skills to connect with his or her behavior, then use that connection to move the client away from a painful spot to a better one.  Sometimes, the move might be life changing, sometimes it would make things only a little better.  For some people, getting even a little better is difficult, but often that small improvement is enough motivation to accept life as it is, and move forward.

Sarge was one of those guys.  He was a cop who took his job seriously, perhaps too seriously.  He worked too long and too hard at putting the bad guys in jail.  He often focused on helping a stranger’s family while neglecting his own, never considering that they might be called upon to prove their love some day.  He just assumed it would always be there.

Because he was willing to work long and hard and to make great sacrifices, the chain of command loved calling on him.  They used him and abused him, frequently giving him assignments that other cops might decline.  Nights.  Weekends.  Holidays.  Time he should have spent at home.  As he benefited from more and more departmental approval, he got less and less of it from his family.  Only they never voiced their disapproval, instead, they made the slow disconnect that takes place when family ties aren’t nurtured, until one day, one very important day, there was just a thread left.

As will happen, some event so heroic or some event so tragic will instantly make obvious how tenuous and yet how necessary that thread can be.  For the hero, it is there for everyone to touch and be touched until the connection is made strong again.  For the victim of tragedy, and this is the business of the hospital, the thread is a lifeline, sometimes thin as a spiders web, almost invisible, but stronger than steel.  It was Sarge’s only hope.  Only sometimes seems an exaggeration.  Not this time.  There may have been hope in some future technology, but that would be stretching probability.  Depending on a family that he had all but burned out was far less of a stretch.

One afternoon while working at his house, Sarge had a headache.  Before he could go in the house and complain about it, he went down, having, for some reason, blown all the connections in his brain stem, the regulatory center that controls vital functions, the trunk line of his wiring system.

Without this part of the brain functioning, most people don’t live very long.  It is essentially your life center, but it doesn’t have much to do with the way you think.  That comes from another part of your brain.  It also doesn’t have much to do with the way you feel.  That comes from still another part of your brain.  So you can lose almost all physical functions if just the wrong part of your brain stem goes down, and you can still be totally aware of what’s going on around you.  That’s what happened to Sarge.  The stroke caused him to grow short of breath and crumple to the ground as the communication lines from his brain to his body were severed.  Messages weren’t getting through, so his muscles didn’t know what to do and they just stopped working.  Sarge became a lump, with no control over any physical functions.  Actually, almost any functions.  I would find out about that later.

The respirator kept him alive in intensive care, and when he left there for the rehab unit several months and a half million dollars later, the physical therapist kept his muscles alive, preventing total atrophy.  The speech therapist spent more than a year trying to teach him to use some other part of his system to make his lungs pass enough air to create some sound.  No luck.  The occupational therapist tried to get his hands to do something.  They couldn’t.

The social worker assigned to the rehab center was young and energetic.  He was a nice guy, competent in his craft, and everybody seemed to like him.  Everybody but Sarge.  Sarge was still a cop, and he didn’t like a lot of people.  What he liked even less was being trapped in a dying body with a fully functioning brain.  He needed a target for his wrath, so the young social worker never had a chance.  Someone in the social work chain of command thought that I might, so they called me to take over the case.  Thanks.

All of Sarge’s doctors and nurses briefed me on what had taken place up to that point.  Not much.  Too much damage had been done.  As I listened to the list of horrors that he had endured and the prognosis for improvement, I wondered more and more what the hell I was doing there.  A year of the best treatment money could buy, at a cost of more than a million dollars, with every type of therapy possible and all he could do was lay in bed, receive food through a tube and be glad that he finally got off the breathing machine.  I started to wonder what he thought he was doing there.  Who could live through that?  Who would want to?  I found out that Sarge would.

I was already trying to find reasons not to dwell on my own mortality while treating a guy who, somehow, after a year of torture with minimal results, was willing to fight every inch of the way.  Me?  I felt like such a wimp.  I was ready to give up because he seemed so hopeless to me, but he would never give up until he died.  I was chosen to try to help him, they said, because I used to be in law enforcement, like Sarge.  They thought I was a tough guy, like Sarge.  They thought I wasn’t afraid of anything, like Sarge.

They were wrong about that.  I was terrified of someday ending up like Sarge, but I didn’t want anyone to know that, so I took the case.

Sarge was told that he was getting a new social worker before I went up to his room to see him, so he was prepared for me.  I was not prepared for him.  They told me he couldn’t talk, and that he raised his eyes, the only part of his body he could still control, to say yes, lowering them to say no.  He kept them in a dead stare when he was upset.  The nurses called this his “I’m giving you a ticket” look.  They didn’t tell me that he could still laugh and still cry, two primitive reflexes that apparently weren’t impaired by his injury.  I managed, without actually trying, to elicit both of those two reflexes in the first ten minutes of our meeting.

While those reflexes may not have been disturbed, they were disturbing to me.  Usually, if I say something to make someone laugh, I can just let it go.  If I make someone cry, I feel it is my responsibility to try and work with that to see where it goes.  In this case, there wasn’t much room for it to go anywhere, not when the person crying couldn’t go anywhere or even talk about the possibility.

Start where the client is.  What if the client is nearly dead?  What if the client can’t do much of anything?  What if the client will never be able to give anything to anyone ever again except his presence and a few eye movements?  What did I have in common with the situation that would allow me tap into his world and make a connection?  The very thought of starting where Sarge was had me wanting to head to the Prozac bar for a long night of overindulging.  I felt guilty for just being able to walk into his room.  For being able to talk.   Hell, for being able to do anything, and for ever complaining about anything.  I needed help.

“Hello. Dr. Anderson?  It’s one of your students from the class of ‘72.  Yeah, that is a long time ago.  Say, I’ve got a question.  Do you guys still emphasize starting where the client is?  Good.  I’m having a little problem”.

I explained what the problem was.  I was having a little trouble finding a connection point.  He listened patiently.

“How do you feel when you go into his room?”


“Terror.  That’s a good place to start.  Multiply your terror times ten.  That’s where he is.  Try to get close to that.”

I thanked him for his advice, although I wasn’t necessarily feeling gratitude as I headed back to Sarge’s room.

“Hey Sarge, what’s up?”

The “ticket” look.

“I thought we might talk about how you feel about everything today.  Well, I’ll talk.  You can just give me a yes or no look, OK?”

Eyes up. So far so good.

“Last night I was thinking about how terrified you must be.”  This was the ER approach I was used to.  The staff in rehab might take a month to get to this subject but in the ER there were only a few minutes to get right to the point, and those minutes had to be taken advantage of.  It was both the ER style and my own style to be that direct, but it was risky using that approach outside of the ER.

His eyes went up.  They filled with tears and he cried for at least ten minutes, the longest I ever spent just listening to a person cry.  When he stopped, I apologized.

“Sorry Sarge.  I’m used to the ER.  We’re pretty blunt down there.”

Eyes up.

“You’re a cop. You know about that.  Don’t they send you guys to blunt school or something?”

He laughed. We were making progress.

It was time for lunch.  A nurse came in and poured it down a small tube that connected directly to Sarge’s stomach.  He didn’t seem to mind the intrusion.  It was a little much for me.

“I gotta get back to the ER.  Do you want me to come again tomorrow?”

Eyes up twice.

I forced myself to go see Sarge three times a week.  The visits were always the same.  We started with some painful feeling that I assumed he had been experiencing and he cried and then we talked about something else.  Sometimes we watched TV for half an hour, me with a running commentary about whatever stupidity we were viewing together.  We laughed a lot and it seemed to help me with the process, but it was obvious that he needed it more than I did.

Then one day, my girlfriend of several years decided to end our long-term relationship in a very painful way.  Maybe, like Sarge, I hadn’t paid enough attention to someone who loved me, and she decided to leave without me seeing it coming until it was too late.

Until then, I was only feeling my fear and imagining Sarge’s pain.  The fear was indirect, something I just had to overcome, a fear that anyone might experience.  With a little effort, I could always put it away in one of those safe spots where it wouldn’t bother me.  The tiger is back in the cage.  But suddenly, a real tiger was out of the cage and I couldn’t talk to Sarge about his losses without thinking, and experiencing my own.  We danced around this subject for some time, as it wasn’t right for him to have to deal with my troubles when he had so many of his own.  I did most of he dancing, since it was difficult for Sarge to bring things up himself.  But the fear we both had of losing a woman who once loved us unconditionally was too painful to get into.

Sarge had a spelling board, a funky, square shaped contraption that had all the letters of the alphabet spread out in each of its quadrants.  Through the painful process of pointing to a quadrant and asking if the letter he wanted was there, we could slowly, very slowly, spell out anything.  But Sarge never brought up the subject of desertion.  I was still making the list of all the reasons my woman should have stayed with me and I’m sure Sarge had an equally long list of why his wouldn’t.  We didn’t want to go there.

But one day I couldn’t stand the charade any longer.  Had it not been my professional duty to confront issues, no matter how painful, I don’t think I would have done it.  On a personal level, most anyone would naturally try to find a way out.  But this was a different deal. It was my obligation.  I was getting paid.  People expected me to overcome.  Kill the tiger.

“Sarge, my girlfriend left me last week, ran off with a guy I thought was a friend and I feel almost suicidal, like no one is ever going to love me again.  Did you ever feel that way?”

The instant sobbing shook him so hard he was in danger of falling from the wheelchair he lived in.  I stood behind the chair and steadied it and when we lost face to face contact I couldn’t control my own tears any more.  We cried together for longer then I had ever cried before.  When we were both done, I felt a lot better.  I don’t know if he did.  I don’t know if he ever told anyone, but I do know that he was very much aware of my feelings that day.

I left shortly thereafter, but when I returned in two days, he was ready for me.  Preparations were being made for Sarge to be moved from the hospital to his home.  He had his board out and he looked like he wanted to start spelling.  We began the long process of eye writing, guessing and frequently misspelling so badly that I couldn’t shorten the time any by guessing what the end of a word would be.  After a half-hour, we decided it was time to tackle another big issue, his friends, the other cops he used to work with.

His long time partner had been reluctant to visit, and when he finally did, he walked into the room, saw Sarge hooked up to all the machines, threw up, fainted and then left in a wheelchair as soon as he woke up.  He seldom visited after that and braced up with a few drinks whenever he did, frequently leaving in a wheelchair again because he was too drunk to walk.  The other guys at the station, haven gotten wind of the situation, couldn’t seem to get up for the experience in person either, but instead made a video with some police equipment, and sent their hellos along on the TV.  Better than nothing, I guess, and it some ways forgivable, but nevertheless, I would have hoped for more from guys Sarge had entrusted his life to.  I guess putting your physical life on the line for a partner is not nearly as scary as putting your emotional life on the line.  A different kind of macho.

Sarge was getting ready to go home, and he had spelled his most important message for me.  More than anything he wanted to communicate to his friends that no matter what had happened to the physical part of him, the real part of him, who he was, hadn’t changed.  He was going to need his friends more than ever when he was home all day with just a nurse’s aid for company.  He hoped the reason his friends hadn’t come to visit was the hospital itself, not his condition, and that once he got home it would be more like old times, with his buddies stopping by for a few beers, or in Sarge’s case, a few wines.  Beer bubbled too much when it was poured into his feeding tube and caused him to bloat up.

Maybe I could have helped Sarge write a letter or maybe I could have called some of his friends and told them how he was and how much he wanted to visit with them.  But I didn’t think it would have much of an impact.  I wanted them to see Sarge, to see that he looked pretty normal, he just couldn’t talk or move on his own. I wanted to force them to confront their reluctance to help a helpless friend.  I needed to have something more visual.  I needed a video!

Now, the friends had become my clients.  I had to help them overcome their fears.  I had to start where they were.  They had sent a video, so we would send one back.  Brilliant, I thought.  Now all I had to do was convince Sarge, his treatment team and family that this was a good idea.  At one time I had entertained thoughts of being a documentary filmmaker and studied the craft briefly, so I knew I could do it.  But I didn’t know if I’d be allowed to.  I called a team and family meeting and told them what I wanted to do and why.  They didn’t have any better ideas, so I got the green light for my project.

I drew up a list of forty things I thought Sarge would want to tell his friends.  Things that seemed normal under the circumstances.  Things that would call upon the friendship to continue.  I would bring the list to Sarge and let him give me the eyes up or down for each item and then I would take what was left and work it into a script with me acting as the voice for his feelings.  I would interview his nurse, his doctor, his physical therapist and his occupational therapist.  I would let his first social worker, who actually looked a lot more like a social worker than I did, be interviewed too.  I would film Sarge in a variety of settings so the friends would have an idea what he would look like.  And then, I would do what he needed and wanted most—I would become his voice.

When I made the list of messages I thought he wanted to send and we went through it, I was never sure if Sarge was even aware of those feelings in himself before I presented them.  Then I thought I was crazy to think that because what would he be doing there for the last year but laying around thinking about himself and how he felt.  He should have been acutely aware of his feelings after the experience, but who knows?  I sure didn’t.  I guess in the end it didn’t matter much.  At least by giving the eyes up or down he was able to acknowledge his acceptance, and that was enough for the time being.

We made the video and it was better than I hoped it would be.  He cried when I showed it to him.  His family cried when I showed it to them.  I hoped that his fellow officers had a strong reaction when they saw it.  I hoped the strong reaction would be enough to get them to visit Sarge as he lived out the rest of his life in a lifeless body.  To me, it was a really great piece of social work.  I started where the client was and took him as far as I could in the direction he wanted to go using all of my creativity.  In the process I learned things I thought I would never have to know and discovered things about myself I never knew were there.  Some of them I liked, and some I knew had to change.

I hope the video worked and Sarge got some of what he wanted.  I never had the heart to find out, and without regret, lost contact after he left the hospital.  I had to go back to the ER where I belonged, to resume my regular duties, only now as a slightly better person with a long way to go.

This event happened about twenty-five years ago when video was in it’s infancy. Everyone didn’t have a cell cam or HD anything. Pretty basic VHS tape just being used by police departments and some budding filmmakers like myself. It remains, to this day, an intervention I am totally proud of. Not only does it represent Start Where The Client Is but also that every social worker should bring every thing they can to the intervention situation. Places you’ve gone. Things you’ve read. Stories you have heard and on and on and on. YOU are integral to the intervention so bring your best game….

Dividing line


About robertjlanz

Author and health care professional.
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