In whose best interest?

[Anonymous]

The details of this case have been altered to ensure the anonymity of those involved:

Sophia is doing her placement at a local hospital, working with people experiencing acute mental illness. A patient, Irene, was recently admitted to the unit after she cut the cord of her refrigerator with a pair of scissors because she was hearing voices coming from it. Irene has a long history of concurrent disorders (living with psychosis and substance use disorder), and incidents like the one described above have become recurrent in her life. She has flooded apartments and has set apartments on fire, and consequently, has been evicted from several properties over the years. Hospital staff is familiar with Irene due to past admissions for the aforementioned reasons.

Upon her last discharge, Irene agreed to a community treatment order and was placed in a residential care facility because she was deemed incapable of living independently in the community. However, due to the fact that residential care facilities are voluntary, Irene left soon after, abandoned her community treatment order, and fired her community outreach team – she highly values her independence and therefore did not feel that she needed the support once she was out of hospital. Subsequently, Irene was not attending appointments, taking her medications, or receiving any sort of formal support in the community.

This admission, it has become increasingly apparent that Irene is a danger to herself and others, as she acknowledges that she did not have the foresight to understand that cutting the refrigerator cord with a pair of scissors was unsafe – she only wanted the voices to stop, and she thought that was the only way to silence them.

When Janice, Irene’s psychiatrist asked why Irene fired her team in the community, Irene stated that she did not need their support. This could illustrate that Irene does not have much insight into the severity of her mental illness.

Despite these concerns, Irene has been deemed voluntary and competent, and will be returning to the community in the near future. Irene tests very well with occupational therapy, and therefore, on paper, she appears perfectly competent to live independently. According to Sophia’s supervisor, Matt, Irene will not be considered as a candidate by adult protection. Because she is stable on the unit, and there is an increasing need for beds, there is no legitimate reason to keep Irene inpatient at this point, and subsequently, she will be discharged very soon. In terms of housing, Irene has actively been searching for apartments while in hospital. She has refused living in any type of supportive care environment, because as has been mentioned, she values her independence and does not feel that she needs to be monitored.

As a future critical social worker, this case has been an ethical struggle for me. On the one hand, it is crucial to recognize that social workers must respect the dignity and self-determination of their clients. In Irene’s case, it is clear that she yearns for independence, and rightly so – no one wants their every waking moment to be monitored. However, social workers are also charged with the responsibility of balancing the rights and needs of their clients with the needs of society. Irene’s return to the community potentially poses risks not only to herself, but also to the greater good of those in the community. In other words, Irene’s past unsafe living practices (i.e. cutting electrical cords, flooding apartments, and setting apartments on fire) illustrate how she has put her life, as well as her neighbours’ lives, in danger (albeit unintentionally). Thus, there is a fear that she will continue to make unsafe judgments once she is back in the community if she does not agree and adhere to a long-term treatment plan.

Questions:

1. Is there a way to balance this client’s right to self-determination while simultaneously serving the greater community that has not been considered? How?

2. Is it paternalistic to believe that it is potentially dangerous for this client to return to the community, especially without any formal supports in place? How can one come to terms with feeling this way?

3. What ethical dilemmas do the resource constraints add to this case?

4. With whom might you advocate around your concerns?

5. How would you go about advocating and what would the nature of that advocacy be?

6. What would you do in this situation?

Thank you for taking the time to read this case study – I look forward to hearing your feedback!

[Anonymous]

Thank you for your post. This is a very difficult case, which there seems to be no easy answer to. I admire Irene’s desire and determination for independence.

Questions:
1. Is there a way to balance this client’s right to self-determination while simultaneously serving the greater community that has not been considered? How?
 It is extremely difficult challenge to always meet the needs of everyone. Although balance is always the goal. Social workers are always being pulled in manly directions. Janice could be honest and upfront about her own concerns about safety of Irene and possible safety of others around her. Highlighting first that Irene has never intended to hurt herself or others. Janice’s honesty could be refreshing to Irene.
2. Is it paternalistic to believe that it is potentially dangerous for this client to return to the community, especially without any formal supports in place? How can one come to terms with feeling this way?
 I personally do not think it is paternalistic of you to feel concerned for this person and the community’s safety. We go into social work wanting to meet the needs of clients. Physical safety is more then a need it is a right. One could work through these emotions through critical reflection with fellow colleges. This may lead one to see that there is only so much a person can do. We are social workers although we are humans also. You want to make sure this does not continue to show up with future clients in the form of countertransference. So it is important that you are able to get to a place where you feel you have done all you can do.
3. What ethical dilemmas do the resource constraints add to this case?
 The resource constraints play a huge factor in this case and sadly many other cases. If they could have kept Irene’s bed in the hospital a little longer then further talk with Irene could have taken place. Maybe exploring her reasons for independence and if how this independence has played out in her life. There needs to be a place of transition for people leaving the hospital and entering the community. This location would lead to less restraints on in-hospital resources and also elevate patient’s confidence and reduce possibility of another admission in the near future.
4. With whom might you advocate around your concerns?
 I would first talk to the clinical leader on the floor she is leaving. Also brainstorm with fellow social workers about possible creative ideas to approach Irene with plans following discharge from hospital. Maybe seeing if she has any family or friends as supports who would advocate for her if her mental health began to change again.
5. How would you go about advocating and what would the nature of that advocacy be?
 I would first need to have Irene apart of whatever I did. Explaining clearly and openly my reasons for advocating some form of support while in the community. She may not agree at first although would like that she was apart of the process and decisions. This may not happen fast, although I would be persistent in where I stand on safety concerns.
6. What would you do in this situation?
 I would have Irene reconsider cutting off all connection with relationships she has fostered while in hospital. Explaining how she is important and there are people like Janice that really care and want to see her happy. If independence is what she wants it is something she should have. Asking her to give me some time to talk about alternative ideas to reduce the risk of danger. Know she wants to enjoy her life independently in an apartment.
 Maybe having a whole team within the community setting was too much. The amount of people involved in her care could have contributed to the need for her to rebuild her independence. It might be good to try motivational interviewing with Irene to explore her goals. This may highlight her want for independence and reasons why she fired her team. When this is brought forth the steps for her to continue to have independence could be discussed. Janice could state that Irene’s goal seems to be to avoid returning to the hospital. To do this she could explore a worker checking in on a temporary time frame where and when she wanted. MI could also be what could create change talk when she starts to connect the dangerous situations from the past with the present and the future goals of independence.

Thank you for sharing.

[Anonymous]

Hi there! Thank you for sharing this case. It reminds me of something that recently occurred in my placement; therefore I will be drawing upon some of my own experiences in order to answer the questions.

1. This is a difficult question, especially since independence is something that the client clearly wants. However, the safety of others is also important, as the client has previously engaged in some very unsafe behaviours. Instead of framing it as an either-or scenario, I would frame it thusly: If Irene was to hurt someone because of these unsafe behaviours, how would that affect her mental health in the long term? For example, if someone had been hurt, or worse, had died when Irene set fire to the apartment, that is something that she would have to carry with her for the rest of her life. Under the law such a scenario might result in a conviction, or even a prison sentence. I cannot image that prison would be a good and healthy environment for this client. Because Irene does not seem to have insight into the severity of her mental illness, the harm that she could cause another could potentially weigh very heavily on her during her moments of clarity.
2. I do not think that it is entirely paternalistic to believe that it is potentially dangerous for this client to return to the community. In your example, you say that she acknowledged that she did not have the foresight to understand that cutting the refrigerator cord with a pair of scissors was unsafe. My understanding of informed consent surrounding degrees of psychosis is that a client must be able to understand the consequences of not getting treatment. In this case, her impaired judgment about unsafe behaviors is a lack of insight into her condition and the consequences of not receiving help.
3. Reading about the resource constraints was frustrating because I have come across this situation in my placement as well. This lack of resources is a result of our neo-liberal system where care is commoditized and services are cut in order to meet budget constraints. Unfortunately in this scenario, it appears that because the client does not present as in need at the moment, it provides an excuse to deny her a this service.
4. In this scenario, I would wish to speak to those who had previously served as her community outreach team. In doing so, I would hope that we could debrief and discuss possible solutions and outcomes for this particular case.
5. In saying all of that, it is important not to lose sight of what is most important here, and that is the client’s needs. In order to be an effective advocate for the client, I would need to speak to the client herself in order to learn about her strengths and needs. It is evident that the client has fought hard for her right to self-determination, and I would want to fully acknowledge that. Unfortunately, we do not live in a society that is very safe for those who have mental health related needs, and ideally I would want to come to find a solution that empowers the client.
6. As I was saying in the above, I would want to have a conversation with Irene in order to validate her experience with the local hospital. In doing so, I think it is important to discover the meaning that Irene ascribes to this experience. More specifically, I would want to ask her what she wanted and expected from the services, as well as what her goals for the future are in relation to the problem. If living on her own is what Irene desires, we could start looking at how we could make that possible while reducing the risk of harm. However, I also must acknowledge that I am a social worker and not clinically trained in psychiatry. I think that it is important for us to recognize that we may not have all the answers for this particular scenario. Thus, more interprofessional dialogue between the social workers, her therapist, and the other health professionals involved should be advocated for in order to explore how best we could meet Irene’s needs, while also supporting her independence.

[Anonymous]

Thank you for posting this case. It is really thought-provoking and a challenging situation. I respect Irene’s struggle for independence and self-determination.
1. However, finding the right balance is not an easy fix especially in a neoliberal environment that promotes individualism over collective forms of association and community living. As a potential social worker, I think that self-determination is a coping strategy that results in a society where individuals are left alone to care and support themselves even during times of ill-health. Therefore, finding the right balance for Irene’s self-determination and greater community safety would require a structural approach that would examine how society’s values, practices, structures and systems of organization produce escalating factors that creates feelings of vulnerability for persons such as Irene. Therefore, there is need to establish a community support group where Irene would have the space to assert herself, share her strengths and experiences and feel valued and supported by persons who have similar experiences. Through the community group, persons such as Irene could identify their felt-needs such as safety, trust and work collectively to meet those needs and even take collective action to to change practices or services that have proven ineffective at the organizational level. It will also be important to help Irene understand how important and meaningful her life and well-being is for the overall interdependent well-being of others. Not to make her feel that her life and living is solely her responsibility. Family involvement or the involvement of those she loves would be vital. Taking time to explore the relationships in her life eg children, spouses, parents, friends, community etc would provide insights into her strengths, skills and abilities. Having been through rough times and struggling for self-determination, a strength-based perspective presents potential opportunities for persons like Irene.

2. Is it paternalistic to believe that it is potentially dangerous for this client to return to the community, especially without any formal supports in place? How can one come to terms with feeling this way?
I think it would be paternalistic to feel that it is potentially dangerous for Irene to return to her community. First, there is no community in this case rather what Irene has to return to is a house with probably no one, no friend and to emptiness; to a neighborhood that stigmatize her as a person with mental health. The feeling that Irene would be potentially dangerous to her community stems from the social worker’s unconscious fear of harm and need for self-protection and the protection of individual rights and properties. These are neoliberal values. The question is whose interest are we protecting? It would be important for us as social worker to critically reflect on our feelings, their sources and factors that drive these feelings especially in order to guard against transferences that may potentially influence our judgments. If Irene wants to go back to her home, I will explore this need with Irene, work with her to establish a community support team, and develop a transition plan that will give time to monitor her over a period of time.

3. What ethical dilemmas do the resource constraints add to this case?

The issue of resource availability is obviously an important one. The allocation and use of resources are driven by values that we find important in the society. Persons such as Irene needs to spend more time in the hospital or shelter while working on a transition plan but with neoliberal cut-backs on health and socially-related issues, keeping persons like Irene in the hospital for longer periods would be unwelcome. The dilemma between keeping Irene longer in the hospital and serving persons in emergency situation is a decision.

4. With whom might you advocate around your concerns?
I will advocate to my supervisor and higher managers and those involved in the care and treatment of Irene to approve a transition plan that would be based on an inter-professional approach and the development of a support group for those in similar situation like Irene.

5. How would you go about advocating and what would the nature of that advocacy be?
I will work with Irene as a partner to discuss and develop a transition plan, identify others who are in similar situation to form a support group. Identify actions that needs to be taken by Irene and by others. Use the transition plan as our advocacy document to be presented for brainstorming, review and suggestions by supervisors, managers and colleagues

6. What would you do in this situation?
Like I mentioned earlier, I will work with Irene in a every step, develop a trusting relationship where she will see me as a partner rather than a social worker trying to fix her.

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