Involuntary Client & Mental Health Practice

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    All details have been modified to ensure anonymity of those involved.

    A family has contacted the agency that you work for to report that they think their son, Brian (aged in his mid-twenties), is suffering from an extreme case of schizophrenia. They note that they feel his symptoms have been ongoing for a number of months and, as a result of going untreated, have worsened to the extent that he has become both unpredictable and, at times, aggressive. They are worried for his safety and well-being, and, knowing your agency’s mandate, request that you attend their home to check in on him and do an assessment to determine if he needs to be taken to the hospital voluntarily or, depending on his presentation and willingness to attend the hospital, involuntarily.

    You attend the home where the family lives with the aid of police. After discussing the client’s situation with his family, you ask to speak with Brian and conduct the assessment to get a better picture of his mental health; however, it is soon discovered that Brian is hiding in a bathroom. You speak to Brian through the bathroom door, during which he refuses, in a monotone, circular, and somewhat catatonic-style of voice to engage with you and states that he does not want to go to the hospital and does not feel he needs treatment. Based on the collateral gathered from the family indicating Brian’s potential mental deterioration, as well as Brian’s catatonic-style of presentation through the door, you contemplate whether you should take Brian into involuntary care under the Involuntary Psychiatric Treatment Act (IPTA-which outlines that a client can be taken into mental healthcare involuntarily based on imminent threat to self, others, or a high likelihood of physical or mental deterioration). On the other hand, you also consider the lack of direct assessment and visual on Brian that is leaving out potentially important information such as the extent that Brian’s functioning has become impaired by his symptoms, as well as the need to balance his rights to self-determination and autonomy with any clinical decisions that you make. You are therefore left with a major ethical decision—whether or not to take Brian into involuntary care—that you must act on in-the-moment based on the information in front of you. Should you decide to take Brian into care based on the extent to which the collateral you have received indicates that he meets the grounds for IPTA and his current presentation, he may receive long-needed treatment that could benefit his mental health and his life as a whole; however, his right to autonomy would also be neglected. Conversely, if you do not take him into care, you will hold his rights to self-determination and autonomy as paramount, but also leave him susceptible to the potential for ongoing mental health deterioration and impacts to his functioning.

    The IPTA can be viewed here (most relevant section to this case is s.14, found on page 9).

    Questions to consider:

    1) What would you, personally, do in this situation, based on the information provided?

    2) To what extent do you believe client autonomy needs to be upheld in the context of mental health presentations that reflect a potential risk to clients and others?

    3) Where do you perceive the line needing to be drawn between respecting a client’s rights to self-determination and autonomy, and ensuring that they are able to stay safe and that their mental health does not worsen?

    4) To what extent do you believe practitioners should value the collateral received from family members? Is it enough to make decisions about a client’s care?

    5) How do you perceive involuntary mental healthcare as fitting in with anti-oppressive social work practice?

    6) What is your perspective on the Involuntary Psychiatric Treatment Act, especially s. 14, as a piece of legislation that provides a guiding point for mental healthcare in Nova Scotia and, by extension, mental health social work practice?

    Jordan Z


    Since Brian is locked in his bathroom and does not want to be admitted to the hospital, or talk to any medical professional I would explain to Brian what my concerns are and the options for him. I would tell Brian that his family has called me because they are concerned with his well being. I would ask him if he feels safe, if he is thinking of hurting himself or others. If he says no to both of these questions and since this is my first visit with Brian, I would not admit him involuntarily without seeing him for myself. However if he answered yes to those previous questions I would be obligated to involuntarily admit him. However I would do my best to convince him of the benefits of going to the hospital voluntarily.
    Although his family made me aware of his symptoms, I can not go by their perceptions alone and would need to do a full assessment. His family did not indicate that he was at harm to himself or others and has not broken the law or made threats so neither myself or the police have reason to bring him in in-voluntarily beyond knowing that he has a mental illness. There is also no mention of a substitute decision maker for Brian, although it is clear that he is able to make his own decisions.
    I would ask Brian if he feels comfortable meeting with me another time, perhaps the following day, or if he has any other medical professionals that are helping him and if he would feel more comfortable talking to them. I would ask his family to watch Brian’s behaviour over the next couple of days and to call me back if Brian’s behaviour become worse.
    In regards to drawing the line between respecting a client’s rights to self-determination and autonomy, and ensuring that they are able to stay safe and that their mental health does not worsen, it depends on the support network the client already has. For the moment, Brian is being taken care of by his family and he is not a threat to anyone so there is no immediate pressure to have him admitted. Brian’s case would be different if he did not have a place to sleep or his family’s support. However I do see the positives for involuntary care, because being a support for a family member who has a mental illness is a big responsibility and there can be a relief for the family knowing that their loved one is receiving help. But being involuntarily admitted to a psychiatric facility does not mean a patient will be cured of all ailments. Many times psych wards are stressful, especially when you can not leave, and do not necessarily think anything is wrong with you. Simply put, involuntary mental healthcare does not fit with anti-oppressive social work practice, but sometimes being anti-oppressive is not an option.
    The IPTA is the law that guides our practice. Do I think think that a person should be involuntarily admitted simply because they have are acting as if they have a mental illness, as stated in s.14? No. But I do believe that the act can be used to protect people who are vulnerable to harmful situations. There are times when mentally disabled people do not have supports and need police and medical intervention. However the act is carried out, it should be done with the client’s best interest in mind, which is not always possible.

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