Inadequate Resources for clients in Psychosis

[Anonymous]

For the purpose of this case the names and personal identifiers have been changed. I have a client who is in her late thirties named Jessica. She is living in my supportive housing facility due to COVID. The goal of the housing facility is to temporarily house 85 people during the pandemic to decrease the spread of COVID-19. We have a clear intake and conduct form that every client has to sign before they are given a room. The code of conduct outlines the behaviour that is expected of clients and staff. One of the mandates is that there is no tolerance for the abuse of staff or other residents. If a person abuses staff or clients, there is a three strike policy and then they are evicted from the building. The first warning is a verbal warning. If behaviour does not improve the client will receive a written warning and then a 24-72 hour bar from the facility depending on the severity. If the client does not improve after the 72 hour bar then there is an eviction notice sent to the site supervisor. The site reviews the case and determines the outcome. My ethical dilemma with Jessica surrounds her mental health as well as abuse of staff. There have been several incidents over the past month where Jessica has threatened staff with physical harm. Jessica is an active crack/cocaine user and regularly is in a state of induced psychosis. While Jessica is in psychosis, she has specifically threatened to go to my and my coworkers houses and burn them down. When she is not using, she explains to staff that she needs to keep her housing in order to regain custody of her children who were taken by Child Protection Services due to her drug use. Jessica has expressed that she would like to get clean. As staff we have tried to find her a detox or rehab facility she could attend in order to get clean. But because of her drug induced psychosis, and complex mental health problems, all detox facilities and rehabs have declined to take her. She could pay out of pocket to attend a rehab facility, but treatment can cost thousands of dollars. We have also tried to contact acute care teams in order to help her cope with her Complex Post Traumatic Stress Disorder and past life trauma. But again because she is in active addiction and actively in psychosis, they cannot admit her. As a worker, it feels like there are no options for her and if she continues to escalate and threaten staff she will be evicted. Jessica is on her final 72 hour bar. Without adequate mental health support, she will end up on the streets again.

1)As service providers how do we stay trauma informed with clients who experience Complex Post Traumatic Stress Disorder?

2).As a worker, I find it ethically complicated to try to support a client who is actively threatening me with physical harm while also dealing with the reality that there is little to no mental health treatment or support available to her. How do I balance my own needs for safety with the needs of a fragile service user in a system that has few options?

3)If you were the service provider, what other avenues would you explore to support her?

[Anonymous]

Thank you for sharing this case example, Drew. I have not participated in an ethics forum before, but I will try my best to answer your questions.

1) I think service providers can stay trauma informed with clients who experience Complex Post Traumatic Stress by upholding the guiding principles of safety, choice, collaboration, trustworthiness, and empowerment in practice, even in the most challenging situations. I think it is important for service providers to create conditions and behave in ways that can help service users feel more physically and emotionally safe in the practice setting. For example, they can communicate with service users in a non-threatening way. They can show empathy and validate service user feelings and experiences. Service providers can also use collaboration to ensure that decisions are not made for service users, but with them. As such, service users and service providers can explore options together.

2) I, too, would find it difficult to try to support a client who is threatening me, and also face the reality that this individual has very limited supports at present. If I were a service provider in this situation, I would advocate fiercely for mental health treatment and support for Jessica. I would exhaust all options within city limits, and even look at resources in nearby communities if necessary and feasible. Perhaps there is a facility or program out there somewhere that could help her, and not turn her away because she is actively in addiction and psychosis. I would also take steps to take care of myself. I would practice boundary-setting in an effort to keep the stress at work from having significant lasting impacts on me at home. I would practice self-care. I would use the tools of mindfulness and meditation to keep me present and aware of how I am feeling and coping. I would reach out to a trusted colleague or therapist. I could debrief about the case with my colleague, and perhaps even discuss it and its effects on me in therapy whilst maintaining the strictest confidentiality, of course.

3) If I were a service provider working with Jessica, I could collaborate with her to develop a case plan around getting clean to increase chances of accessing mental health treatment and supports. I would make sure that this plan is not imposed upon Jessica, but rather is something that she wants for herself. In the meantime, I would support her at the housing facility as best as I can, and remind her about its zero tolerance for abuse policy. I would work to build rapport and trust in hopes that an improved working relationship might reduce Jessica’s threatening behaviour.

[Anonymous]

I would educate myself more on complex post-traumatic stress disorder. I would provide a trauma informed lens where to figure out the triggers that can cause the escalated emotions that the client is experiencing. I would find an alternative plan where I can look for a shelter/housing facility with less barriers when it comes to substance use so that when it comes to having to provide help to the client, they are sheltered in another place in the meantime. I would look for programs that can include harm reduction so that the client can wean off of the substance at the same time get the support that they need. I would include the five principles of trauma informed care which are choice, collaboration, safety, trust, and empowerment. Ask the client ‘what we can do to support them?’.

 Levensen, J. (2017). Trauma-informed social work practice. Social work, 62(3), 105-113. ‪https://web-b-ebscohost-com.ezproxy.library.dal.ca/ehost/pdfviewer/pdfviewer?vid=1&sid=97f0975f-ac2e-4067-a80e-93dbd355c506%40pdc-v-sessmgr04‬

[Anonymous]

Hi Drew, thanks for posing this real life case example. As someone who has worked with youth and adults who have been in states of drug induced psychosis I can understand some of the barriers, professional approaches, and safety concerns you and your coworkers are experiencing.

1. As future service providers I think we can use a trauma informed approach for people with PTSD by recognizing that the person has lived through trauma that may have changed the way their brain processes information such as becoming triggered more easily when their brain/body feels they are being threatened and responds with a fight, flight, or freeze response. As psychosis can feel like a bend in reality and information can be interpreted differently then someone who is not is psychosis, your client may be perceiving information that is triggering to them in the home and it is important to create a stress free and trigger free environment for your client. This could be done by talking with them (when they are not in a state of psychosis) about what changes they would like to see to remove triggers. This would also help you build rapport and engage in collaborative problem solving that may help them feel saver in the home.

2. As their is a concern for your client and staff safety in the home as a result of her mental health, it seems this program is not a good fit for her as it is only meeting her housing needs. Its unfortunate to hear that their are not mental health and addiction resources to her. This leaves me wondering if there is even a hospital that she could have access to as she could receive help as her mental health and addictions could be treated by health care professionals. If there is truly no mental health supports or a hospital to treat her for her mental heath, I would advocate for her to be admitted to a program that would meet all her needs else where.

3.From your description it is evident that the program is meeting her housing needs but not her mental health and addictions concerns. in an active state of psychosis is a reason to take her to psych emerge where she will be able to see a psychiatrist. If she is actively going through drug induced psychosis she will likely be admitted to an acute care unit where they will assess her mental health conditions. Any hospital unit will also have the resource to help your client go through medically managed withdrawal to help her with her substance use disorder. Social workers on the unit can also help her connect with community resources for additions and help her find housing as well which may include helping her access income assistance if required.

[Anonymous]

Hi Heather, great post. I think you did a great job at explaining the key themes of trauma informed care and how to use it in practice. I also think empathy and validation can be very effective with their client as it will help to deescalate the situation and help her get back to her baseline. I think that speaking to her in a non-threatening way and using collaboration can help build rapport so Jessica can build more trust with the staff. Perhaps if she builds a stronger and more positive relationship with staff she will respect them more and engage in less threatening behaviour.

I also found it hard to imagine what it would be like to not have access to mental health care resources. this shows how privileged we are to live in the community with hospital and community based mental health and additions resources for support. Unfortunately it seems like she would have to travel to access the resources to met her needs which present its own challenges and struggles for the client. I think we would have to weight the benefits and negative aspects of her going to a program that it outside of her community and how this might affect her.

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