by Lauren Dennelly, MSW, LCSW
Through my work as a social worker on a voluntary inpatient psychiatric unit, I have seen how complicated the mental health system can become when a state entity must get involved with psychiatric care. Despite the paperwork that patients sign stating that they are “voluntary” for treatment, when they begin treatment on the unit, their attitudes often change quickly and dramatically from when they were seen in screening. Suddenly, I have tearful patients in my office, stating, “I don’t belong here. I want to sign out.”
Now, in situations like this, our basic social work instincts kick in and we “start where the client is,” right? I console patients, let them know we are all here as a team to help them, and encourage them to take medications and go to group therapy.
This usually works well, and patients are able to calm down and discuss feelings of fear and shame about being hospitalized and in need of psychiatric care. We can begin work on how to focus on what one can and can’t control, and with the assistance of intensive 24-hour support from the inpatient team, patients are able to see that they are experiencing a temporary scenario.
However, there are some instances in which patients are simply not convinced (despite having signed paperwork to indicate otherwise) that any of the treatment on the unit will be helpful. They vehemently deny that they tried to commit suicide and/or will try to commit suicide (again, despite screening reports that indicate otherwise), and launch into the “this was all just a big mistake” speech.
Again, we start where the client is. Working on a voluntary psychiatric unit does not mean that, as the practitioner, I am free from seeing patient denial. In an acute inpatient facility, however, there is not much time to work through the denial process with the patient as I might in an outpatient setting. I have a week, tops, and that’s if the insurance company will give me that much. If the patient continues to insist on signing out, I then respond with, “There’s a document called a 48-hour notice....”
This is when the process becomes complicated. In researching the New Jersey laws on my own, I came across a document entitled The Involuntary Civil Commitments Resource Binder, published by the New Jersey Court system to help make sense of the basics of the process. Involuntary commitment procedures vary by state. In New Jersey, the patient can sign a document called a “48-hour notice,” in which patients have 48 hours to be rescreened by the original screening entity that found them to be appropriate candidates for the inpatient setting.
Many patients incorrectly interpret this as having to spend only 48 hours on our unit and state that they have been told by the screening entity that after 48 hours, they are free to go. Whether or not patients are actually told this or this is their interpretation is something I may never know. However, I do know I see the aftermath of this incorrect assumption on a weekly basis, sometimes multiple times in one week.
I provide education to patients, informing them that it is their right to sign the notice if they so choose, but that in doing so, if the screening entity continues to feel they are a danger to themselves or others if released, the screening entity may then involuntarily commit them, and they will be transferred to another facility that has an involuntary bed. Often, exasperated patients will ask me, “How is this place really voluntary if you either go voluntarily or they [screeners] commit you?”
It is at this point in the conversation that the idea of self-determination comes to my mind. How can I assist patients in maintaining their right to self-determination while underlining the importance of making a decision that is going to be in their best interest? The NASW Code of Ethics states:
Social workers respect and promote the right of clients to self determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients’ right to self determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others. (1.02 Self Determination)
In assisting clients to “identify and clarify their goals,” I can take the approach of asking them to discuss what their goal is—getting better or getting out. Getting better may mean further treatment—specifically the treatment that professionals are currently recommending. Being discharged before treatment is provided may be in direct conflict with patients’ goals of getting better, as it doesn’t allow the treatment process to begin. “But I DO want to get better,” I’ve heard in response. “I just don’t think being here is going to help me do that. This is making me feel worse.”
Refocusing patients on their goals and respecting their right to disagree with the treatment they are receiving while firmly informing them of their rights as patients relates to respecting patients’ dignity and worth:
Social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients’ socially responsible self determination. Social workers seek to enhance clients’ capacity and opportunity to change and to address their own needs. Social workers are cognizant of their dual responsibility to clients and to the broader society. They seek to resolve conflicts between clients’ interests and the broader society’s interests in a socially responsible manner consistent with the values, ethical principles, and ethical standards of the profession. (NASW Code of Ethics, Ethical Principles)
Encouraging patients to be advocates for themselves while at the same time teaching them to take responsibility for their behavior is something I view as an important part of helping them resolve the conflict between what they want and what society at times dictates is appropriate. Many times, I come across patients who are willing to lay the blame on the mental health system or even society as a whole, but fail to recognize their own self-efficacy. It is often difficult for me professionally to see a client’s full potential and have to watch patiently as he or she spends precious treatment time fighting the very system that is trying to help him or her, rather than engaging in treatment.
A colleague once said to me, “Maybe this is the treatment.” More specifically, maybe helping to support patients while they go through their process of fighting the system is exactly the kind of support they need in that moment, even though it may not be the practitioner’s idea of productive treatment.
For myself, staying grounded and understanding that I’m not the solution to a client’s problems but rather a support along his or her journey, however bumpy that journey may be, has been a vital realization in my work.
New Jersey Courts. (2008). Involuntary civil commitments resource binder. Retrieved from http://www.judiciary.state.nj.us/civil/ICC_ResourceBinder.pdf
Kaplan, L. E., & Bryan, V. (2009). A conceptual framework for considering informed consent. Journal of Social Work Values and Ethics, 6 (3). Retrieved from http://www.jswvearchives.com/content/view/130/69.
Cameron, L. (2009). The day self determination died. The New Social Worker, 16 (2). Retrieved from http://www.socialworker.com/feature-articles/ethics-articles/Ethics%3A_The_Day_Self-Determination_Died/
Lauren Dennelly, MSW, LCSW, works as a licensed clinical social worker in Pennsylvania. She has also worked in New York and New Jersey in a variety of settings.