The spotlight has been on the rollout of the National Crisis 988 number.
In the recovery world, there is yet another push to have peers and nonclinical workers at the frontline of crisis intervention strategies. But, unfortunately, there has never been a time to understand the real issue at hand.
I am speaking as someone who has experienced heartache, grief, hallucinations, and the chaos of my mismanaged altered state in my personal and academic life as a student.
People living with a mental health disorder, diagnosis, or issue with their health are unique in their needs as individuals. We all require different forms of treatment, support, and often help. As a psychotherapist, state regulation continues to outline the provision of emergency protocol for people in an acute psychiatric crisis.
The letter of mental health laws in the US, for better or worse, makes it as clear as day when someone is at immediate risk of serious harm to himself or others. The question then becomes: Is the law congruent with clinical practice for determining the risk of self-harm or injury to others?
This metaphysical line during a risk assessment seems unclear and very different across the US. Across state lines, state mental health laws prescribe other protocols in emergency mental health situations.
These state laws inform clinical judgment daily in Emergency Rooms, 911 calls, and everyday community interventions by licensed mental health crisis workers.
There seems to be a big grey area for clinicians to misinterpret state laws. Assessing safety and risk continues to be problematic for clinicians doing crisis work.
Quickly and precisely, clinicians must decipher between spiritual emergencies, still not requiring in-patient hospitalisation or a psychiatric evaluation and observation. However, when the is a risk high of people hurting themselves or others, clinicians shouldn’t be gambling with life.
Self-harm is the act of deliberately inflicting pain and damage on your own body. Think about it: as therapists, we assess risk all the time. However, suppose we are doing our jobs right and are genuinely person-centred. In that case, we should be using every technique in our toolkit to treat outpatients where they are, regardless of how society views mental health diagnoses.
People with mental health diagnoses falling into clinical grey areas need the most help.
Grey areas exist where clinical research and skills don’t have the teeth to intervene effectively for people in distress. Significantly impaired people have disjointed beliefs about what they can and can’t do.
On many levels, a person’s insight into their impairments or limitations is stuck in time before their brain suffered structural or neurological damage. The apparent disconnect is where best clinical practice goes grey.
This grey is the same discolouration staining clinical practice. Therapists and emergency workers, in general, continue to fumble during crises. Clinicians often think therapy and therapeutic work must target symptoms primarily. If a patient is to experience relief from their disorder, the sign must be eliminated or at least inactive. In rounds, the patients I describe are often the ‘problem patients and ‘frequent flyers’ in the ER.
The real issue is clinicians’ failure to identify the best possible course of treatment. The clinical greyness I described earlier often makes choosing the proper treatment fit difficult. The result is the deferral of progress, favourable outcomes, and the stabilisation of clients in distress. My point is this is happening because clinicians have their blinders up and only see a tiny part of the bigger clinical picture.
Clinicians do not understand that clinical symptoms are only a remote part of their patient’s distress. So, as a therapist, I listen to other practitioners talk about their patients.
In doing so, therapists toss around ideas and consult with each other. Sometimes, my head spins when I listen to their views when discussing clinical grey areas and how this impacts treating people with SMI conditions.
The conversation usually takes a dip at this point, and a more sombre tone as therapists’ most significant weakness in their clinical skill set often falls into this under-researched area of human behaviour.
To truly support healing, therapists must focus on strengthening the human self-driven capacity to direct the world around them.
Driving treatment forward can be complex and considerably challenging. However, moving patients closer to their dreams and goals requires supporting patients to strive to obtain or maintain the standard or quality of life they deem appropriate.
This cheering patients to reach their potential takes work and can be very demanding and unforgiving. As a result, practitioners need to be more meticulous with treatment plans. For some, completing monthly projects is a way to stay evidence-based.
In treating SMI populations, targeting symptoms is not the best clinical pathway or course of treatment to address the biggest clinical issue. Instead, depending on the individual’s goals, more attention must centre on quality of life to drive treatment ahead.
Practitioners must strengthen the weak points in a person’s quality of life. Metaphorically speaking, clinicians need to extinguish the house fire before rebuilding the home or cleaning it up enough to be livable.
To this end, clinicians must create pathways to reach the desired quality of living. Unfortunately, therapists working on the symptom reject the organic and human implications of SMI on the body. As a result, some people never experience relief from their symptoms.
Due to extreme chronicity or untreatable impairments, sometimes, people never experience relief from chronic issues. Therefore, focusing on regular, immovable matters is an excellent way for a therapist or peer to hijack a person’s sense of control and safety.
Clinicians need to refocus treatment to target and identify the weak points in a person’s functioning regardless of the symptom-creating impairments. Instead, clinicians and peers dwell on unresolved and chronic symptoms.
I recommend strengthening a person’s weaknesses to help them recover. In the end, patients more in command of their lives are more likely to be clinically stable. However, recovery requires long-term stabilisation only achieved by clinicians relentlessly driving treatment forward.
Like the emphysema patient on oxygen, sometimes daily maintenance is the only way to keep moving and is the extent of recovery for people with SMI. Only seen with social work is only seen in strictly medical settings.
In medical hospitals, patients may need to quickly learn new limitations to living from untreatable illness or disease. So be an honest therapist. Communicate with your patient. The objective, the authentic dialogue, goes further in the long term.
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.
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