You are retiring? Who is going to help me now? Direct care workers hear these questions often when terminating with a client’s or leaving for a new position. In the end, the reason why clients ask this question boils down to one of the oldest axioms: survival.
I am a mental health therapist and disability rights advocate. During my tenure advocating for my clients, I’ve noticed some commonalities when it comes human behavior and the clinical process. By and large, clients want to know how they will survive after their workers retire or move on to a new position somewhere else in the mental health system. People with severe chronic and unpredictable symptoms stemming from a mental health condition undeniably need a reliable, trustworthy, and rational point person. A point person can be anyone on a treatment team. A point person can be a therapist, friend, family member, psychiatrist, or case manager.
Believe it or not, there are circumstances in which good leadership is not dependent on clinical savvy or ability to carry out complex case management. Instead, good leaders take on responsibility, own their mistakes, reap the benefits of reflecting on learning moments, and are passionate in their approach to the helping process. My first clinical supervisor would always remind me of having sound ethical and moral underpinnings when providing psychotherapy in a mental health treatment setting. All too often, brave and compassionate clinicians absorb the blame of their colleagues and lose face or damage to their reputation when entirely plausible interventions fail or were ineffective in impacting or providing relief to a patient’s symptoms, seemingly increasingly resistant to treatment. That is why so many people in the helping profession, psychologists, psychiatrists, friends, and family, sometimes take a step back and distance themselves and the person in crisis who would benefit from that sort of attention in providing their treatment.
When people need a lot of care, premature stepping down to a lower level of care or discharge from a program or inpatient facility sometimes does not work out for people with a severe mental health condition. People in these circumstances may still require extra help and may even fail out of treatment given fewer supports in their life or the reduction in the frequency and intensity of psychotherapy or pharmacological therapy. Patients can stumble or cycle back into the system without identifying how to compensate for their mental health treatment’s fall-off and titration.
Even minor adjustments to treatment for people who benefit from routine can exacerbate symptoms. Patients recovering from a mental health disorder are likely to be blindsided when transitioning into a new level of care and step down in support. In some cases, depending on how difficult or compromised a person’s situation is, it can be enough to trigger, invoke anxiety, and other more severe symptoms to reactivate.
Leaders, and natural point people, must sometimes make ethical and value-based decisions for their loved one or patient. These are decisions, which, at times, impact the care and provision of their loved one or patient’s treatment.
Patients need to believe in their therapists to help them make the right decision. There are undeniably times when people with specific mental health diagnoses experience symptoms that interfere with ethical decision-making and, in many cases, are appointed lawyers, and health proxy, in advance of losing their capacity. The theory here is that while patients retain their ability, they can make the right treatment decisions for their ongoing care. A point person may need to step in with a case like this or take the lead in these emotionally difficult situations for loved ones. With this said, when treatment takes a problematic direction, the point person becomes even more critical. In some cases, a more restrictive treatment fit may need to discover for the safety of the patients or family members. For an adult, mental health patients, in particular, who are likely to have wrap-around services may already be living in treatment homes in the community. Many patients with severe conditions live out their lives in community adult homes in a supervised living situation. These adult homes are little more than free-standing and self-sufficient inpatient wards scattered and dispersed in the community.
I am a person with lived experience who uses the mental health system and accesses it at various levels. I have never been so reliant on the course and its resources. In turn, we have become conditioned by it. If the system failed me or my needs bump up against its interests, I would not be so jarred or shaken that my well-being, world-view, and quality of life are at risk. In my tenure as a peer advocate and social worker, I have observed people so dependent on the system they unlearn how to do things independently. Ever watch a person so ingratiated into the system; it becomes more important than how they benefit from it than how they relate to the world. I have witnessed this manifest in different ways. I have seen clients yell and scream at their workers in the community on a supermarket cashier lane, in community centres, or hospital waiting rooms and ER’s, just because they have no other emotional outlet to vent. I have also experienced being yelled at because my clients were so isolated and disconnected from natural supports. Since, as a mental health worker, I was a representative of the system, both literally and figuratively. It was the only option for some clients to release their extreme build-up of negative emotions and disturbing thoughts. The cases I describe are not as rare and far, and few in between, as you may think in today’s mental health treatment settings.
These are not even the most dysregulated, most chronic, and most isolated people. I have worked within a very populated, economically diverse region with a vast spectrum of needs and a range of supposed functioning. Often the case with patients, the focus is ‘getting better’ and not thinking about or concerning themselves remembering their condition’s extreme nature and the danger of their complex situations. The fact of the matter is, though, as a clinician, putting a client like this back into more a systems perspective and making it clear how important it is to stay connected to the system or face inevitable relapse. Patients losing access to mental health treatment sometimes incite patients to make noise and complain to their local community mental health board. The irony is that these boards can reinstate services in limited clinical landscapes. Mainly, if a person’s symptoms begin to overtake their coping mechanisms and their behavior becomes so alarming, the patient rebounds into the system through the hospital. Such is the public safety argument for mental health treatment in the community. I get it. As social workers and peer advocates, we want to fix our clients’ problems. Sometimes, due to the system’s limitations or constraints, we clinicians have to go ahead and do things for our clients. Instead of teaching people to remember their appointments or make sure our clients attend a session, we social workers go on and make reminder calls or reach out to clients to check in with us instead of teaching clients to access services independently. These are all micro-level and clinical examples of learned helplessness in play.
Whether due to immigration, race, medical, age, and ageism, all of these intersections that impact learned helplessness contribute to its power over the population, furthering our reliance on systems that disconnect and estrange us from the broader community. We need to get to know our neighbours, the people around us, who live among us. Whether we are helpers or help seekers, living is about survival, and people are more likely to succeed banded together and looking after one another. Being reliant upon a system, and letting something else define the problem for us, instead of the community identifying its issues, estranges us from network building and bonding with our peers. We have lost the essence of community building and humanity’s very fabric, which is not afraid to band together and change what needs changing. The less human contact, the less empathy, the less we care about one another and what is at stake for our friends, families, and those we love to get what they need for themselves and be better.
Max E. Guttman, LCSW is a psychotherapist and owner of Recovery Now, a mental health private practice in New York City.