Why We Need to Move Away From Jailing the Mentally Ill

Today, after decades of deinstitutionalization of all but the most critically ill patients from state mental hospitals, America's jails are the central address for the mentally ill. Two million people with serious mental illness are incarcerated each year. There are 10 times more people with mental illness in the justice system than are being treated in psychiatric hospitals, and 60 percent of jail inmates had a mental health problem in the past year.

Inmates with mental illness are incarcerated for longer periods of time and are more likely to be placed in solitary confinement. They are twice as likely to be involved in an assault and to sustain injuries during an altercation in jail. They seldom receive treatment while incarcerated, and many leave jail sicker than they arrived.

As a society, we pay an extremely high financial and human cost for criminalizing behavior better addressed by diversion into mental health treatment. Incarceration costs for those with mental illness run from 60 percent to 20 times higher than those for than other inmates. It isn't hard to see why jurisdictions that have implemented diversion programs are saving millions of dollars every year.

Yet research shows that with treatment, most low-level offenders with mental illness can return to productive lives and remain crime-free. Diversion into treatment can address the underlying conditions that may have led to their inappropriate and criminal behavior.Certainly for violent offenders with mental illness, incarceration is in the best interest of public safety. But for low-level, non-violent offenders, who constitute the vast majority of those with mental illness in our justice system, incarceration is expensive and inappropriate. Many are jailed for offenses such as trespassing, disorderly conduct, loitering or disturbing the peace -- offenses often precipitated by their underlying illness.

Nationally, momentum toward diversion is beginning to build. Among the most promising developments is the formation of Stepping Up, a collaboration among the National Association of Counties, the American Psychiatric Foundation and the Council of State Governments Justice Center that not only promotes alternatives to incarceration but also provides tools for jurisdictions to measure their progress and documents successful demonstration projects. Projects like Stepping Up have a lot to build on in the experiences of jurisdictions around the country that have moved aggressively to divert mentally ill people from their justice systems.

Miami, for example, saves $12 million a year on jail costs alone by diverting people in mental health crisis to treatment instead of arrest. Portland, Ore., saved $16 million in jail costs in a two-year period by pairing police officers with mental health professionals to deliver coordinated services in the community. And diversion through the use of special mental health courts has saved Bexar County, Texas, $10 million a year.

One of the oldest and most exemplary diversion programs is in Memphis, where the police department has worked with mental health specialists since 1988. This pioneering program has reduced arrest rates, lowered rates of injury to officers and to individuals with mental illness, increased access to mental health treatment, and reduced rates of jail suicides. The model has been codified into a rigorous curriculum that is being used by a growing number of police departments.

Hampden County, Mass., won an Innovations in American Government Award for its diversion program, which lowers recidivism for mentally ill inmates with proactive screening and service delivery. Inmates receive treatment while locked up and upon leaving get a discharge plan, medications and an appointment to see a community mental health provider. The program has reduced crime and the use of emergency-room services, and released inmates show improved mental health and greater success with employment and family functioning.

All of these are commonsense approaches, but one can't help wonder why they are bright spots of innovation rather than ubiquitous. Every jurisdiction could benefit from reducing the numbers of non-dangerous mentally ill people in their jails. Diversion to treatment helps families, offenders and taxpayers. But each of these initiatives requires stepping outside of habit -- a police officer walking in the shoes of a behavioral health counselor, a corrections employee thinking like a health care broker. Making diversion ubiquitous calls for leadership and a willingness to work across organizational lines.

Life Story Work May Help Improve Quality of Life for Dementia Patients

Patients with dementia who record their life stories may experience an improved quality of life, according to a new preliminary study led by researchers at the University of York’s Social Policy Research Unit (SPRU).  There is also evidence that working on the project together may help family members and caretakers develop more positive attitudes toward the dementia patients.

The study finds that in order to truly benefit from life story work, however, the patient should be interested in doing the project and should remain in control of what goes into it and who sees it.

Life story work (LSW) involves recording aspects of one’s past and present life along with future hopes and wishes, often in a book or folder or, increasingly, in music, film and multi-media formats.

The researchers found that many health and social care services in England now incorporate life story work, but the ways in which they do so vary considerably.

To gather evidence on life story work in dementia care, the researchers reviewed existing literature on the subject and also conducted a national survey of family caregivers and dementia service providers. They listened to firsthand accounts of people with dementia, family caregivers, and professionals through a series of focus groups and also conducted an in-depth analysis of life story work in six care homes and four hospital wards.

The study concluded that life story work has the potential to help people with dementia, but a full scale evaluation is needed.

“People with dementia and their family carers have played a pivotal role in identifying nine key features of good practice in life story work,” said lead researcher Kate Gridley, research fellow in SPRU.

“This includes not assuming that a person wants to do life story work, and respecting the person’s wishes about what goes into their life story and who will see it. However, these good practice approaches were not always followed.”

“The study identified some improvements in staff attitudes towards people with dementia in care homes where they introduced life story work, and improvements in quality of life for some of the people with dementia, although the numbers were small,” Gridley said.

“The cost of delivering life story work is relatively low, and staff felt that doing life story work encouraged interactions with family, and helped staff to get to know the person with dementia.”

Source: University of York

Self Care, Clients as Tenants, and Peer Support

 The issue of achieving “good” self care at any time during one’s social work career is a near universal one. First, what “good” self care means varies from social worker to social worker. Some social workers need to have exercise in place to clear their heads. Others need excellent group supervision. Let me try to discuss, though, why self care itself feels like such a complicated issue. Let me also attempt to address part of why there is something about the dialogue about self care that can feel so frustrating and odd.

    Simply put, the work we do is exceptionally hard. Yes, there are a lot of professions that do very complicated and difficult work. I am not arguing that. I am arguing that social work is uniquely complex for the psyche to metabolize. The fact is that when we are performing our job really well, we will see our clients walk out feeling tremendous relief. It is hard to say exactly why this relief is happening. There are a million reasons, and the reason is likely different every time. But there is likely a unifying reason why this relief is taking place, and that is because something transactional has occurred in the dyad between the client and the clinician.

Our Clients Are With Us

    We ask our clients to rest their minds at our doorsteps. Many times, what we are also asking our clients to do is to part with significant pieces of their stress, to make them freer to function. But this stress, on a psychic level, has to go somewhere. I would argue that it floats into our minds, and it rents out space in the crevices and vacancies of our buildings. I think that as a social worker, it is fair to think of yourself as a building manager, with many different units, large and small. Clients come in and they make deposits in our minds—in our buildings—and we accept this. The clients don’t stay forever, and we never know exactly how long they will stay, but we do hold things for them.

    This is why, sometimes, we are in the shower and it feels as if we have a sudden realization about a client. We might be doing the dishes and the same thing will happen. We have our clients with us in ways that can feel both intimate and haunting. We have clients with us in ways that we can often feel ashamed about. This is because there is a lot of dialogue out there about boundaries and the need to have them. In fact, we need to have really good ones. That is true. But this dialogue often produces an internal sense of shame or a punitive feeling driven by an overly regulated super ego that keeps us from sharing just how truly “with” us our clients are.

    I want to echo that Carl Jung spoke eloquently about a collective unconscious and a psychological field that we coexist in with our clients. This field does not end when our work day ends. This fact does not dismantle, whether or not boundaries are present. But somehow, there is some confusion about all of this, and many new social workers are made to feel that if they take their work home with them, they have failed at creating good boundaries.

    My hope is that self care begins with separating these two dialogues. There is an important dialogue to be had about boundaries. There is another important dialogue to be had about how intense our treatment relationships feel and that we often wake and sleep with this, which does not render us unprofessional, naïve, or ill-prepared for this work. Self care, in my opinion, begins with a level of acceptance about how deeply penetrating this work can feel, coupled with a surrendering of shame around that reality. We often conceive of self care as a highly behavioral intervention, and it can be. It is also a mindset that allows us to recognize the gravity of our work, the extent to which it is not fully understood by other fields, and the very dangerous way that we, as social workers, can inappropriately police each other’s boundaries in a way that silences our very real experiences of having our clients as tenants.

Peer Support for Self Care    

    My best advice, when it comes to self care, if I have any advice at all, is that you need to hang out with other social workers. This does not need to happen all the time, but I do think it needs to happen. I think it can and should happen inexpensively. I think it is important to find a community of peers with whom you can talk about all of this shamelessly, honestly, and where the complexity of your role is celebrated and recognized.

    I do not believe that this is something that can easily happen with co-workers. Relationships among co-workers in agencies and nonprofit settings are notoriously complicated. Yes, there is certainly support to be had, and it happens all the time. The cultivation of relationships outside of the agency setting can be a sincerely saving grace, free of the daily politics that dominate your workplace. It will allow you to have a place where you get to say what you need to say freely.

    Beyond hanging out with other social workers, it is of particular import, in our field, to do things that give you renewal. This sounds trite, because it has been said a million times. It can mean journaling, art, exercise. The bottom line, though, is that if you can’t do those things for whatever reason, you need to pay close attention to protecting yourself from the shame that might ensue as a result. There is a very strong relationship between self care and shame, and this is something that I hope you can find yourself feeling particularly on guard against. No one has the self care “thing” down. It is an elusive entity at best, so have patience for its unfolding and mysterious role in your life.

Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. This article is excerpted from her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.

A List of Ethical Dilemmas Facing Social Work

Social workers take on a variety of responsibilities that should ultimately serve their clients' best interests. They try to abide by the code of ethics from professional organizations like the National Association of Social Workers or the International Federation of Social Workers as a way to guide their actions. As in any human services profession, social workers may face a number of ethical dilemmas in their practice. An ethical dilemma involves a conflict between two or more ethical principles.

Right to Self-Determination

One of the guiding principles of social work is respect for the client's right to self-determination. This principle means that the client is ultimately in charge of making his own decisions and finding solutions to problems, regardless of whether a social worker agrees with his course of action. A social worker may provide guidance and help clients explore their options, but she may not allow her own opinions and personal biases to influence the client. This is a difficult dilemma that is created by the social worker's desire to act in the client's best interest and the need to respect his right to act in a way that he feels is best.

Confidentiality

Another common ethical dilemma encountered by both novice and experienced social workers is the right to confidentiality versus the right to self-determination, especially in cases of suicidal clients. Social workers must respect a client's right to privacy and confidentiality, and they may not disclose information about a client without his prior, written consent. Social workers must also respect a client's right to self-determination, that is, his right to choose his preferred course of action. But in cases of suicidality or the threat of harm to another person, a social worker is obligated to break confidentiality to protect her client and the public.

Differences of Morals and Values

All social workers have their own internal value system and set of morals. Despite their best efforts to keep their feelings in check and to respect differences, social workers are often confronted with situations in which their values and morals conflict with those of their clients. For example, a social worker who holds certain religious or moral values about abortion may face an ethical dilemma when trying to assist a teen client who becomes pregnant and wishes to have an abortion.

Dual Relationships

Engaging in dual relationships - meaning having a friendship or romantic relationship with a client - is forbidden by the social work code of ethics. And once a social worker terminates contact with a client, the relationship technically is over. A social worker may find herself in the same social situation or, for example, in the grocery store with a former client and his family. The social worker cannot simply ignore the client, yet at the same time, she may not know how far to take their interaction. These are examples of common ethical dilemmas many social workers face that are difficult to resolve and require professionalism, courtesy and good judgment.

Administrative Dilemmas

Not all ethical dilemmas in social work involve direct client contact. According to social work professor Frederic G. Reamer in an article for "Social Work Today," social workers employed in administrative roles may also come up against a number of challenging ethical dilemmas. For example, directors of human services agencies may need to make difficult decisions regarding the allocation of funds or agency resources. The decision to provide funds to one program and to cut funding from another is just one example of a stressful and trying ethical dilemma social work administrators face.

Generic Human Services Professional Competencies (As defined by the National Organization for Human Services)

The following six statements describe the major generic knowledge, skills and attitudes that appear to be required in all human service work. The training and preparation of the individual worker within this framework will change as a function of the work setting, the specific client population served, and the level of organization work.

1. Understanding the nature of human systems: individual, group, organization, community and society, and their major interactions. All workers will have preparation which helps them to understand human development, group dynamics, organizational structure, how communities are organized, how national policy is set, and how social systems interact in producing human problems.
2. Understanding the conditions which promote or limit optimal functioning and classes of deviations from desired functioning in the major human systems. Workers will have understanding of the major models of causation that are concerned with both the promotion of healthy functioning and with treatment-rehabilitation. This includes medically oriented, socially oriented, psychologically-behavioral oriented, and educationally oriented models.
3. Skill in identifying and selecting interventions which promote growth and goal attainment. The worker will be able to conduct a competent problem analysis and to select those strategies, services or interventions that are appropriate to helping clients attain a desired outcome. Interventions may include assistance, referral, advocacy, or direct counseling.
4. Skill in planning, implementing and evaluating interventions. The worker will be able to design a plan of action for an identified problem and implement the plan in a systematic way. This requires an understanding of problems analysis, decision-analysis, and design of work plans. This generic skill can be used with all social systems and adapted for use with individual clients or organizations. Skill in evaluating the interventions is essential.
5. Consistent behavior in selecting interventions which are congruent with the values of one's self, clients, the employing organization and the Human Service profession. This cluster requires awareness of one's own value orientation, an understanding of organizational values as expressed in the mandate or goal statement of the organization, human service ethics and an appreciation of the client's values, life style and goals.
6. Process skills which are required to plan and implement services. This cluster is based on the assumption that the worker uses himself as the main tool for responding to service needs. The worker must be skillful in verbal and oral communication, interpersonal relationships and other related personal skills, such as self-discipline and time management. It requires that the worker be interested in and motivated to conduct the role that he has agreed to fulfill and to apply himself to all aspects of the work that the role requires.