I worked in a large freestanding full-service HIV clinic in Houston as a Medical Case Manager, assigned to work with young adults, ages 17–24. Unlike many HIV clinics, this one had medical doctors on staff, so clients could view the clinic as their medical home. The clinic offered comprehensive health care, including psychiatric services. Almost anything an HIV patient might need medically was present in the building.
My role was to connect patients with services and resources. In the process, however, I ended up doing far more counseling than anything else. There were lots of relationship issues, and disclosure of HIV issues. The young people were trying to figure themselves out. Disenfranchised individuals have poor adherence to HIV medication schedules and appointments and a low rate of returning to therapy.
I believe, in every sense of the word, in meeting clients where they are; in my practice this meant cultural competency in the use of language. It was normal for me to have pretty graphic conversations with patients, particularly regarding their bodies and sex.
One of my clients was having a difficult time, in every way possible: housing, employment, relationships. He would end up coming to see me, as many of them would, just to talk—sometimes two or three times a week. It was almost as if the clinic were a second home, a setting in which they could feel comfortable.
One of the main reasons for nonadherence to HIV treatment protocol was fear of judgment—worry that someone was going to see them, someone was going to judge them, consider them “nasty” (pick your word). But none of the patients felt judged by me.
So the fact that I was able to get them to come in for appointments, take their meds regularly, keep coming in for group therapy, or just come in to hang out was a measure of success. Now some might have seen my interactions with these young adults as questionable—my conversations with them were more open and franker than many in the building were used to. I might, for example, tell one of the young men to “sit down!” Observers would be shocked since these were young adults, not children, but our relationships were such that I could be a bit more abrupt and confrontational with them than most.
A client to whom I’ve given the name David came to see me and reported, “I’m dripping.”
“Again?” I asked. “What have you been doing?”
“Nothing.”
“How is it that you think you can keep coming here saying you’re not being sexually active and then complain of sexually transmitted diseases?”
“Well, I don’t know.”
“Look,” I responded, “you’re being a ho. I need you to stop being a ho. Can we just talk about that?”
He laughed. I laughed. And then we got into a conversation as to why he was being as sexually promiscuous as he was. I had learned from previous conversations that no one had ever educated him on sex, at all. This was not uncommon. People were having sex indiscriminately and didn’t know why.
They didn’t know how, nor did they know who. So many of the conversations I had were often quite graphic and, by some definitions, vulgar—but using polite words like penis and anus didn’t cut it much of the time. I kept my language as appropriate as I could, but it was always borderline. I knew that. I owned it and had no problem defending it since my numbers were so good.
When I first started, there were five appointment slots daily. And they were lucky if one person showed up. By the time I left there were eighteen slots, and we were often overbooked to eighteen. Adherence to medication and show rates for appointments had been 30 percent before I arrived at the clinic. My rates were 80 percent. People were coming and they were taking their medication. Part of it was just the entertainment value of coming and having these odd conversations with me. But I knew it was my relationship with the patients that created the success.
I knew because I had been doing this for nearly thirty years. I was on the first mobile testing unit ever in the country. The Minority AIDS Project in Los Angeles started mobile testing with prostitutes in the park. I was doing this when I was nineteen years old, long before I thought about it as a profession.
One thing I think is important as a professional is to remember those things that lead to success and kind of codify what might otherwise be considered unprofessional, figuring out a way to actually serve the population in a way they’re going to receive it, and still be able to keep your job and not mess with the reputation of the organization you’re working for. All of this has to be balanced. And it’s a really hard thing to do. Really hard.
David came in on Friday, telling me his symptoms were back again.
“Are you still dealing with the same individuals?”
“Well, yeah.”
“So, you introduced someone new to the pool?”
“Well, yeah, I had to.”
“No, David, you did not have to. Why did you do it?”
So we had a conversation and, really, he didn’t have to. It was just his unthinking routine—he was going to wake up, turn on his phone, check the various phone apps for where one can find sex, and then sex was going to happen. It was just the norm. His mind and body were operating in a “cog” system, on autopilot, and this is just what he did without thought of person or anything.
Fridays were notoriously slow days at the clinic. It was around one o’clock, the clinic was quiet, and I needed to see if I could get him in to see a nurse practitioner to get the needed treatment. As we’re walking through the building to the medical care unit, there’s really nobody there. We continue our conversation, using some colorful language—nothing really horrible, and not loud or rambunctious, but for us, a normal conversation about his behavior. A nurse I will call Jenny was at the nurse’s station.
I approached the nurse’s station and said, “David really needs to see the nurse practitioner this afternoon. Can he be seen right away?”
“Yes,” she replied. “I’m sure they can see him. Just give me a minute.”
While we waited, David and I continued our conversation, peppered as before with graphic language. After a few minutes, Jenny interrupted us and said loudly and sternly, “You two are being quite inappropriate! I’ve just never heard anybody talk like that before. Ever!”
What I wanted to say in response, but didn’t, was, “Well, I don’t know who you know, but that’s how they all talk. And why are you yelling at me in front of people? Why are you yelling at me at all? Much less in front of people?”
I didn’t like being corrected publicly, in front of the patient. And I really didn’t think it was her place to say anything. That’s where my head was. But I bit my tongue and got his appointment. I went back to my office and David went on about his business.
There’s a backdrop here. There is generally some animosity between social workers and nursing staff, a sort of tension existing in virtually all hospital settings. So this was not the first time a nurse had said something to me that didn’t quite rub me the right way.
I complained to my supervisor about this latest incident, “Could you please do something about Jenny’s attitude? I can’t keep serving the patients while fighting what feels like a battle against the nurses.”
“Well, you’re the social worker and therapist,” my supervisor replied, as she had before. “You’re supposed to know how to talk to people and make things work. You go figure it out.”
And I’m thinking to myself, Well, hell, they’re on the clock and they’re professionals too. What kind of training do they have that they don’t know you shouldn’t chastise a coworker in front of others? That is so offensive to me.
Out loud, I said, “I ain’t got nothing to say to that woman. And you better tell her not to say nothing to me. And that’s how we’re handling it because I’m not her therapist. I’m the case manager, not her supervisor, so it will not fall on me to do any corrective action with this woman.”
Over the next several weeks, I simply avoided Jenny when I could. My office was on the second floor and she always worked on the fourth floor, so there was really no reason for us to interact unless I initiated it. I went to other nurses when I needed to get something done.
Then one day, I saw her right by my office. I don’t know why she happened to be there, but she was.
I called her over, saying, “Come holler at me right quick.”
“Yes, brother. Yes. What do you need?” she responded loudly.
In my head, I’m saying, What do you mean ‘brother’? If I was your brother, you wouldn’t have treated me like you did.
Instead, I said, “I’m gonna need you to fix your tone. Why do you yell? Do you know how aggravating that is? Do you know how many times I’ve heard people complain about you? And I didn’t say nothing about it, but now you done did it to me. So, I got something to say about it and what you not going to do any more is yell at me. At a minimum, your tone need to be changed.”
She looked me and simply said, “I’m Nigerian. That’s how we talk.”
That stopped me dead in my tracks. I had not previously considered that her tone might have been an “ethnic yell,” if that’s what we want to call it. I had to ask myself, Is hers a normal yell, or just not normal to me?
“Okay,” I said to her, “but what do you think? Maybe you could be a little less yelling?”
“Brother, I would never say anything to offend you. I know how much you love these kids. You do your job and you do so much good. But do you have to use the language, though?”
“Actually, yes I do. By using their language, I become them. But I’m also aware that I am becoming them, so I’m able to keep the proper boundaries. I really am purposeful in how I interact with the young people. It’s not that I’m just some idiot walking around with random words coming out of my mouth, unaware of what the words mean or how they might be perceived. Can you understand that?”
“I do understand what you’re saying, but I don’t like the crude language. I never have and I never will. We just don’t talk like that. I’m old,” she said, pointing to her sure-enough gray hair. “Could you maybe just do it in your office instead?”
I realized that after coming at her as hard as I had, she had still heard and understood me. And the way I came at her probably didn’t surprise her. She’d seen me be assertive, even blunt, on a regular basis. She had to have. But now she had demonstrated a certain amount of acceptance of me, which made me able to hear her. I realized that both of us had felt disrespected in the situation.
After this, our relationship improved. Every now and then I would tease her, threaten to say something that might be offensive to her. She’d roll her eyes in response and keep going with what she was doing. Not long after that she left the HIV clinic. She just disappeared one day. I didn’t know what happened to her.
Some time later, I too left the clinic and took a position as a therapist in a psychiatric hospital. Here, all the nurses are Nigerian, every one of them. And when I work with patients, they often complain to me about them. So, I tell them about me and the Nigerian nurse at the HIV clinic.
“You have to listen to the words they’re saying and decide if the words match up with their tone. If they don’t, there might be something else going on. You’ve got to cut them some slack.”
Then one day, walking down the hall, whom did I run into but Jenny! We were both surprised and greeted each other with a big hug. She had been working in this hospital since she left the clinic. And it turns out, she often tells the story about our interaction too, sometimes in my presence.
“I remember when Steven brought this young man to the nursing station to make an appointment, he was carrying on a real conversation with him, looking out for him. He loved his patients. He took care of them better than anybody else had ever taken care of them. But he can also be rather raw at times.”
That’s it. She tells only that part of the story, with no mention of our later interaction. What she remembered is that I was speaking to the patient, and it made her feel a certain way. I was the one emotionally invested in the interaction, not she. She also sees it through a nursing lens—when she remembers the story, it is about the patient. I see it through a social work lens—when I remember the story, it is about our relationship.
As a sociologist, Mr. Hayes has taught a variety of classes, including Social Problems, American Pop Culture, LGBT Perspectives, Minority Relations, and a variety of social work classes as visiting professor at Lincoln University in Missouri. As a Licensed Master Social Worker, he has acted in the role of therapist, medical case manager, and supervisor of community health workers. Mr. Hayes has assisted incarcerated individuals who have spent as many as twenty-five years behind the walls to successfully reenter society. He has helped navigate patients to healthier living, and through insurance and other barriers that can hinder progress in health and life.
Mr. Hayes’s research interests include best practices in psychotherapy, Black masculinities and shifting roles in African American families, love styles, and learning strategies. Mr. Hayes uses motivational interviewing and a strengths-based approach to cognition behavioral therapy. In addition to client and student success, Mr. Hayes includes the search for joy, peace, and clarity as part of his mission.
