“I ‘bumped into’ this blog [“Doing what’s Right” https://behindthelockeddoors.wordpress.com/2012/04/05/doing-whats-right/] searching for support…I am a masters-level social worker in a psychiatric inpatient unit and I had a difficult experience today. It was a first for me, as I have had this job is this practice setting for only nine months. I suppose it was bound to happen.
“We have a client on the unit right now that is in her thirties, has a long history of bipolar, and is quite low functioning. She receives disability income and her sister receives the money and helps the client pay her bills. The sister rented a small house for the client and has been helping her with daily living skills. The client came to the unit on the 4th in the afternoon; she hasn’t been there for long. Her sister is her main support, her only support.
“The client had stopped taking her meds after her mother died several months ago. She was brought to the unit because she was very labile, had pressured speech, flight of ideas, and was quite irritable. She hadn’t showered for weeks, we were told, and she had cigarettes hidden in her buttocks. She was very unkempt and had no interest in being clean.
“What happened is that since it’s a holiday, we had a substitute doctor today and he came in at the crack of dawn, which I didn’t know would happen, so by the time I got to work, he had discharged five people. I had no chance to talk to him. In calling the client’s family to discuss the discharge, I was told by the sister that she would not pick her up and she would not care for her until she was stabilized. The sister also told me that the client had increasingly decompensated over the past few months, she had no impulse control as she was jumping into the street, asking strangers for rides, providing sexual favors for a cigarette, etc.
“I became concerned about the client going home and being alone. She was still very labile. Some of the staff said she was ‘turning it on’ for effect. I don’t believe she was able to control her affect. Although the client meets criteria for home-based services, I could not put that into place until Monday. I was not comfortable with sending her home to no support and I discussed this with the nurses. They disagreed with me saying she was fine to go home. I said I was concerned. At that point, we still had no transportation for the client.
“I decided to call the doctor and share my worries. He listened and in less than a minute, he agreed with me to keep her over the weekend. Apparently, he had been told by the DON that this person was ready to go. I called the DON before talking to the doctor and was told to go ahead and call the doctor. When the nurse found out that the client was staying, she came by my office and, in front of two other staff, berated me for my decision, also saying that she had no order from the doctor not to discharge and she didn’t have to do it based on my telling her. She said that now the staff have to deal with this patient all weekend and the client had already been told she was leaving today.
“I told her I would speak to the client myself, which I did. The client did get very upset as she lacked the insight to see my motivation and concerns. It is a small unit and several other staff became upset at me and one came to my office and told me he disagreed. This was a mental health tech with only a high school diploma. I explained my reasoning and he still didn’t get it, but he accepted it. I wish I had been able to convince him.
“I think I did the right thing but I have to say it was hard to go against several staff members. In the end, I think the problem is a lack of respect for the training of the social worker, me. I don’t go to a nurse and tell her she’s wrong, the client doesn’t have a urinary tract infection or a bleeding laceration. That’s not my area. But they certainly feel free to challenge my clinical judgment! All feedback is appreciated.”
Here’s my feedback: you have put your own needs ahead of the patient’s. You are young and new to the profession, and what matters most to you is your status. “In the end, I think the problem is a lack of respect for the training of the social worker, me.”
No. In the beginning, the problem is that the patient’s mother died and nobody is inviting her to talk about it. You make no mention of any inpatient or on-going psychotherapy, or grief counseling. A single person in her thirties lost her mother “several months ago” and yet there is no indication you even brought up the subject with the patient.
In fact, you appear not to have talked to the patient at all. Are you not a clinical social worker? The only direct contact you report having with the patient was to tell her that you’d gotten her freedom revoked and her imprisonment continued. How powerful did that make you feel?
The patient comes first. The patient wanted to leave the hospital. You recite an endless list of her behaviors that you don’t like. Tough. It’s not about what you like or how you would live your life. The fact that the patient stuck cigarettes up her butt is wholly irrelevant. You are measuring the adequacy of her lifestyle by your own standards and you have no right to do that. To what degree do you fear losing control of your own life?
For a lot of reasons, mostly venal, the hospital staff wanted to put the patient out and you fought to keep her imprisoned. For what? To get her reestablished on her medications? Drugs are not the solution. Or because you wanted her to be discharged to some lifestyle that resembled yours? She has the right to live any damned way she chooses, including not bathing and having sex with strangers. It’s not yours to decide.
You failed to offer the patient counseling. You did not invite her to talk about her mother’s death. You did not ask her what she wanted. You rejected her lifestyle choices. You fought the entire medical hierarchy to keep her imprisoned when she wanted to leave. You made it all about you and not at all about her. Her spirit was in pain and all you cared about was how her body lived.
“Doing what’s Right” means fighting the system for what the patient wants, not what you want.