sion, they ministrative
should acts
understand and should
the have
ramifications the beginning
of adskills
for undertaking administrative jobs, and they should be capable of doing community consultation. A residency training curriculum that incorporates supervision, administration, and consultation may alleviate some of the difficulties experienced during the introductory phase of community services. Supervision is traditional in psychiatry, but it has generally been given by psychiatrists to psychiatrists. As new categories of workers are developed and as psychiatrists work on teams with other professionals, they may find themselves in charge of the other workers without knowing anything about their training, background, or abilities. A supervisor who is aware of clinical issues and is flexible in his expectations will be able to work more effectively under those conditions. Under the new plan, the resident will supervise community workers, mental health workers, and social work students, all of whom have clinical responsibilities on the team. The resident’s supervisory skills will be evaluated during his weekly meeting with the team’s medical director. Administrative skills are difficult for some psychiatrists to learn, as they often have difficulty changing from semi-passive listeners to active bosses. Under the new plan, the residents will work with the medical director and team leaders to understand the day-today problems of dealing with the system. A didactic program dealing with the application of systems theories within a community mental health center will be instituted; each resident will have to attend. The most difficult and nebulous portion of the new curriculum is the area of community consultation. Center staff discussed the pros and cons of having the residents become involved in community consultation. The nonpsychiatrists seemed to feel that the residents would disturb a delicate balance of center and community and destroy the careful work that had preceded them. Most psychiatrists, however, seem to interact tactfully with the community. The center staff helped design a method for teaching consultative skills to the residents; it will include research on broad psychosocial issues as well as actual consultation in the community. Community consultation will begin in the second year, when the resident will be in the clinic one-half day each week, and will grow until it becomes an important part of his more intensive third-year experience. A resident’s education in community psychiatry must be designed to be relevant to his future, not simply to meet current service needs. Perhaps there are other skills besides administration, supervision, and community consultation that should be included. Training in such areas as emergency consultation, brief psychotherapy, intake, or triage should not be excluded. The emphasis, however, should be on the resident’s learning to do what he will be doing after graduation, not what other team members will do as part of their role-specific tasks.S
Ethical Issues in Community Psychiatry
DAVID I. JOSEPH, M.D. Faculty Member Psychiatric Residency Training Program Overholser Training and Research Division ROGER PEELE, M.D. Assistant Superintendent St. Elizabeths Hospital Washington, D.C. In
delivering
chiatry
mental
operates
community between
health
under
and the the provider
organization
services,
two contracts: provider of services
requesting
them.
community
psy-
one between
the
of services and and the individual
one or
Each party in the con-
tract has a system of ethics and values that determines its conception of what services should be available and how they should be delivered. Often there are conflicts. Using case studies from a community mental health center, the authors discuss many of the conflicts and ways of resolving them. SThe have years.
sociopolitical and ethical received increased attention As one branch of medicine
aspects of medicine during the last 25 more often concerned
Dr. Josephs mailing address is St. Elizabeths Hospital, Washington, D.C. 20032. He also is clinical instructor and Dr. Peele is clinical associate professor in the department of psychiatry and behavioral science at George Washington University in Washington, D.C.
VOLUME
26
NUMBER
5 MAY
1975
295
with the quality of life than with its preservation, psychiatry has felt and has been strongly influenced by these ethical and political forces. Community psychiatry, with its mandate of comprehensiveness and continuity and its direct relationship to both the community as a whole and to the individual seeking assistance, has been a frequent battleground for these forces. Some of the ethical issues in community psychiatry can be illustrated by the case history of Peggy, a 17year-old, single, unemployed girl. Peggy had been in and out of psychiatric hospitals for several years. Her conflicts with her parents had escalated to the point that the court declared her to be beyond parental control. She was admitted to a community mental health center by court order, to be kept there until suitable housing could be found. Two years before admission to the center Peggy had a baby. She planned to give the child up for adoption, but changed her mind at the time of delivery and kept the child, who was being reared by her parents. Shortly after admission it was discovered that Peggy was eight weeks pregnant. She was afraid she would repeat her earlier experience and, after considering other courses of action, requested an abortion. Her parents, however, strongly objected on religious grounds. The center was faced with the decision of whose rights and wishes to support; those of the patient who desired and whose mental health dictated an abortion, or those of the nonpatient clients, the parents, who were residents of the community and were legally responsible for the patient. This case and others we will discuss involve the areas of representation, responsibility, and accountability, as well as morality, personal values, and other traditional ethical concerns. By examining these areas in greater detail, we hope to elucidate a common perspective for approaching ethical issues in community psychiatry. Our views of the ethical issues in community psychiatry grow out of our experience in a community mental health center. Although a center is but one variant of community psychiatry, its comprehensiveness and continuity, called doing everything forever,’ “ ensure that ethical issues will be raised, often with painful directness.2 In our view, the primary task of community psychiatry is the provision and delivery of mental health services to a specified community. It involves two contracts: one between the community as a whole and the provider of services, and another between the provider of services and the individual or organization requesting them. Although such contracts are specifically concerned with the types of services and the manner of their delivery, they are, in fact, based on fundamental ethical principles. Each party has a value system and has strong feelings about its essential correctness. Such ‘ ‘
‘A. F. Pauzetta, Community Mental Lea & Febiger, Philadelphia, 1971. 2 L. J. West, “Ethical Psychiatry
American
296
Journal
of Psychiatry,
HOSPITAL
Vol.
126,
Health: and
Myth
Biosocial
August
& COMMUNITY
1969,
and
Reality,
Humanism,” pp.
226-230.
PSYCHIATRY
a value system, however, is usually taken for granted or is obscured by the more measurable, quantifiable aspects of the contract. Neglect of this aspect of cornmunity psychiatry, and its implications for the relationships between the relevant parties, contributes significantly to the confusing and often heated transactions that one so often encounters. The values underlying any psychiatric system play a major role in determining the types of services offered, the priority of each, and the manner in which each is delivered. We propose that ethics, as they pertain to the delivery of mental health services, should not focus on what is right or wrong in absolute terms, but rather consider for whom it is right and for whom it is wrong. The concept that each party participating in the contract has his or her own values is consistent with a systems approach to such transactions.3 This framework devotes particular attention to the individual components of the system and the nature of their interactions, increasing the opportunity for developing mutuality and what Deutsch has called productive conflict.4 We feel the individuals and agencies of a cornmunity must retain their own values and wishes. Therefore, we have considerable theoretical and practical difficulty with the concept of putting the cornmunity on the couch and treating it as a single unit. In focusing on the delivery of mental health services to a specified community, our definition of community psychiatry resembles many others. It differs from most, however, in that it is not tied to a theory, concept, or body of knowledge and does not specify the goals of the community services. Important as certain tasks, goals, or bodies of knowledge are, they should not be built into the definition of the discipline of community psychiatry. It ought to be defined solely in terms of responsibility to a given community. The theories, knowledge, tasks, and goals that are used in fulfilling that responsibility will vary according to the practitioner of community psychiatry and the community he serves. THE
TWO
CONTRACTS
Many of the ethical issues confronting the community psychiatrist can be understood as growing out of attempts by the patient, the family, the psychiatrist, and the community to define the task of the community mental health center in different ways. Some of the resulting confusion can be reduced by keeping in mind that the center is involved in two separate contracts, each based on a different set of values. In deciding the terms of the contract between the center and the community, it is necessary to consider what is best for the community as a whole. Thus the center and the community may decide to employ their 2 E.
M. Miller
and
A. K. Rice,
Systems
London, 1967. M. Deutsch, “Conflicts: Productive Social Issues, Vol. 25, January 1969,
of Organization, and pp.
Destructive,” 7-41.
Tavistock, Journal
of
Individuals receiving care in a center ought to have the same rights, within the limits of the contract with the community, as those receiving care from the private sector. resources in the treatment of alcoholics, addicts, and psychotics, and devote less attention to individuals with neurotic or characterological problems. Or they may decide that the center will offer only short-term psychotherapy to outpatients. The exact nature of the contract will depend on the characteristics of the community, the resources available to the center, and the interests and professional perspectives of those who set policy. The contract between the center and the individual seeking treatment or the organization wishing consultation is based on a different value system. We feel that, under this contract, the center operates on the same ethical principles as does the private psychiatrist. Such principles emphasize the rights and wishes of the individual, giving far less consideration to the rights and preferences of the community. Individuals receiving care in a center ought to have the same rights, within the limits of the contract with the community, as those receiving care from the private sector. To accord them less would be ethically indefensible and would radically alter the quality of care delivered. Furthermore, in most instances the initial contract between the community and the center is based on the community’s insistence that quality psychiatric care be available to its members, a goal that is best met by following the strict guidelines that operate in the private sector. Since the wishes of the individual patient and those of the community as a whole are often conflicting, the center that operates according to such principles may often find itself at odds with the community. Failure to support the individual’s rights and wishes not only deprives that individual but also erodes the quality of care delivered to the community. Peggy’s case clearly illustrates a conflict. Her wish for an abortion was in direct opposition to her parents’ wishes. Since we see the center operating as the patient’s agent, we elected to support the patient’s wishes. Peggy appealed to the legal system to decide whether or not a minor could have an abortion over the objections of her parents. The court ruled in Peggy’s favor; she had an abortion, and she was placed in a facility for adolescent girls. As individuals we provide mental health services from the tradition and perspective of the doctor-patient relationship, the therapeutic alliance. But the
relationship between the community mental health center and the community differs greatly from the model with which many of us grew up professionally and with which we are so comfortable. The contract between the center and the community permits the center to provide direct mental health services not available through other facilities in the community and to make consultation available to organizations requesting it. Many problems arise, not so much from difficulties in deciding what services are to be rendered but in deciding which system in the community should provide that service. The center is continually under pressure from multipie sources in the community to define itself as something other than a treatment facility: to become a detention home for juvenile delinquents, a nursing home for the elderly, or a boarding home for indigent citizens with psychiatric problems. Conversely the center may try to redefine the school as a treatment facility, the nursing home as a geropsychiatric center, and the courts and the legal system as a therapeutic resource for disturbed adolescents with severe behavior problems. The center’s effectiveness depends in great part on its ability to determine what it can and cannot do, and to state clearly what services it can, cannot, or will not provide. Tempting though it may be, the center must not get caught up in the omnipotent notion that it can answer all the needs of the community or that all human needs fall within the general purview of mental health. The same clarity of purpose must be forthcoming from other institutions in the community. Without such clarifications, the center and those institutions may repeatedly find that they or others believe they have failed to carry out their mandate. OTHER
ETHICAL
ISSUES
The following cases exemplify other ethical issues in community psychiatry. Dale, a 14-year-old boy, was referred to the center by his mother and his school because of his unmanageable, hostile, and aggressive behavior. His difficulties stemmed in part from a congenital hip disorder that went undiagnosed for nine years. The disorder gave him an awkward gait, which was the cause of many jokes. When he was nine he underwent surgery, was in a cast for many months, and was out of school for a year. During that time he received individual tutoring. When his rehabilitation was complete, Dale returned to school but did poorly; he resented the absence of individual attention and frequently got into fights with his classmates. Finally, in desperation, he was brought to the center. His mother was informed at the outset that her son’s treatment would require that she also be involved in treatment. Although she agreed initially, she refused to keep appointments, even after being told that her failure to participate would lead to her son’s discharge. Dale also had difficulty participating in the program. The contract between the center and the community
VOLUME
26
NUMBER
5 MAY
1975
297
specified that the center be a treatment center. Dale and his mother came to the center requesting treatment, and their contract with the center required their active participation. When Dale’s mother refused to participate in the treatment, she broke the contract, and Dale was discharged. As treatment without his mother’s participation would have been nonproductive, retaining Dale on the rolls would have meant that the center was not providing treatment and was not upholding its contract with the community. Thus although the community was faced with the problem of dealing with a difficult adolescent, its wish for the center to be a treatment center was supported. Mrs. W was admitted to the inpatient service with severe depression. Because she had abused her children, the protective services agency was involved in her case. After several weeks she appeared well enough to be treated on an outpatient basis. The protective services agency was afraid she would again abuse her children, and urged the center to delay her discharge from the inpatient service. Should the center act as the agent of the patient, her children, or the protective services agency? The center understood and respected the fears of the agency and was concerned about the welfare of Mrs. W’s children. However, the task of the center was to provide evaluation and appropriate treatment for the patient. Since she no longer required inpatient care, she left the hospital and returned for outpatient treatment. The agency was informed of this course of action, and they handled problems involving the care of Mrs. W’s children. FURTHER
CONTRACTUAL
PROBLEMS
Many conflicts between the center and the community revolve around problems of the young and the old. A woman brought her 72-year-old mother, Mrs. B, to the center with the complaint that she couldn’t care for her any more. She said, My father died a year ago, and since then my mother has been wandering around at night, confused and unable to care for herself. My apartment is too small for her to live with me. Mrs. B was admitted to the ward, and her daughter offered minimal cooperation in the evaluation, treatment, and long-range planning for her mother. Mrs. B was found to be severely depressed; however, she responded to treatment and soon was able to live outside the hospital. Once evaluation and treatment are completed, what is the responsibility of the center to the patient? Does the center have the right to refuse to define itself as a nursing facility for geriatrics and throw the patient out, leaving the family and the community to provide proper services for the care of its elderly? Sally, a 15-year-old girl, was admitted from a large institution for adolescents where she had made frequent runaway attempts and suicidal gestures. After several months she was well enough to leave the hospital, but she had no place to go. Her mother, a “
‘ ‘
298
HOSPITAL
& COMMUNITY
PSYCHIATRY
paranoid schizophrenic, had severely abused her children. Sally and her brothers and sisters had been made wards of the court and the welfare department, but there was no facility that would accept a girl her age with her history. Although she no longer needed hospitalization, she was making the hospital her home. Furthermore, the welfare department insisted that it had a right to reject any placement the center might find for her. Should Sally be discharged and the cornmunity be forced to grapple with the problem of the adolescent with no place to live? If the center fails to discharge Mrs. B or Sally, it violates its contract with the community and becomes, for these two individuals, a nursing home for the elderly and a residential boarding home for adolescents. Such action diverts badly needed resources from patients who require inpatient psychiatric evaluation and treatment. Furthermore, since the community mental health center is structured to be a treatment center, it performs poorly as a home. Finally, if the center agrees to provide shelter for these individuals, it colludes with the community’s failure to provide more appropriate facilities for them. lf feelings did not interfere with judgment, a course of action would be clear; Mrs. B’s daughter would be informed of her mother’s discharge and the provision of care would become her responsibility. The welfare department would be informed of Sally’s discharge and would become responsible for finding a place for her to live. The hope was that after the same process was repeated with similar individuals, the community would realize that the center would not allow itself to be converted into something other ‘than a treatment center, and would build the necessary facilities. It was the spectre of sacrificing Mrs. B for the longrange benefit of other Mrs. Bs, or of abandoning Sally for the benefit of other Sallys, that prevented us from discharging both. Thus Mrs. B remained as an inpatient until an adequate foster home was located, and Sally lived in the hospital until the welfare department was pressured by the courts to agree to pay for lodging at a halfway house. We realize that our course of action regarding Mrs. B and Sally represents obvious inconsistencies. Theoretically and contractually each should have been discharged. These cases are included, however, to empha-
Once evaluation and treatment are completed, what is the center’s responsibility to the patient? Does it have the right to refuse to define itself as a nursing facility for geriatrics and throw the patient out?
size that the center too may often find it difficult to adhere to its contracts. Many times patients try to define the center in their own terms. Mrs. S, a 72-year-old woman with a history of recurrent psychotic depressions, was ready to be discharged from the hospital. She had no family, had a limited monthly income from Social Security, and had a meager wardrobe. She did not want to leave the hospital, where she felt that she had better lodging, more opportunities for socialization, and better medical supervision than she could afford elsewhere. What right does the center have to insist that it is not a boarding home and force her to take any lodging she can afford? Mr. P was a 36-year-old chronic alcoholic who repeatedly presented himself in the emergency room when intoxicated. He was admitted and dried out, but he refused to participate in any therapy. He often had visitors bring alcohol onto the ward. He expressed a wish to withdraw from alcohol and to remain in the hospital, but showed no motivation to change. Should he be allowed to stay? While sympathetic to Mrs. S’s wish to remain in the hospital, we informed her that on a certain date she would be discharged. We assisted her in a search for housing, and before her scheduled discharge she moved to an acceptable, though scarcely ideal, boarding house. Mr. P was discharged because of his drinking on the ward. To have retained him as an inpatient would have continued wasteful use of the hospital’s resources. Mr. P was told that if he wanted treatment he could return and be readmitted. The community mental health center compounds its problems and those of the patient by allowing itself to offer services it has not contracted to provide. Spurred by a desire to help the disadvantaged, the center too often stretches its boundaries and allows itself to stray from its proper task. Thus wards become crowded with nonpsychiatric patients, overworked outpatient departments dispense less than adequate care to ensure that everyone gets something, and everyone, including the community, accepts less than ideal treatment for patients. The intense personal struggles and conflicts brought on by maintaining the boundary and adhering to the contract sometimes make it appear easier to give in. But such action compromises the center’s ability to deliver quality care and leads to other difficulties. Ethical questions are usually addressed with great reluctance because they have no absolute answers and because they seem so far removed from the hard data of basic science. Not to evaluate them with the same industry with which we examine other aspects of the delivery of mental health services is to deny the degree to which they influence the types of care delivered and the way it is delivered. To question, to reconsider, and to re-evaluate our value system and its implications will help prevent patients from being seen as mere symptoms. Our work will thus be conceived as involving more than the delivery of services to a consumer and will be viewed in the broader context of individual dignity and the social values of an entire community.
Patient
Rehabilitation Through Hospital Work Under Fair Labor Standards DANIEL SAFIER, M.A. Director of Rehabilitation Services RUTH BARNUM, M.A. Rehabilitation Counselor Binghamton (N. Y.) Psychiatric Center
Payment
of patients
for hospital
become a matter of stitutions since the the Department amendments to the
work
assignments
has
great concern for mental health in1973 federal court ruling requiring of Labor to enforce the 1966 Fair Labor Standards Act. A work
program in compliance with Fair Labor Standards has been operating at Binghamton (N.Y.) Psychiatric Center since 1971 Certificates from the labor depart.
ment permit the hospital to pay less than the minimum wage for patients in occupational training or in sheltered employment in a regular job. The authors believe that work therapy has important clinical and rehabilitative functions, and that patients should not be
denied court
the
opportunity
for
such
work
because
of the
ruling.
Under a federal court ruling issued in late 1973, the Department of Labor is required to enforce provisions of the Fair Labor Standards Act regarding payment of S
Mr. Safler’s New York
address 13901.
VOLUME26NUMBER5
at the center
MAY
is 425
1975
Robinson
Street,
Binghamton,
299
should acts
understand and should
the have
ramifications the beginning
of adskills
for undertaking administrative jobs, and they should be capable of doing community consultation. A residency training curriculum that incorporates supervision, administration, and consultation may alleviate some of the difficulties experienced during the introductory phase of community services. Supervision is traditional in psychiatry, but it has generally been given by psychiatrists to psychiatrists. As new categories of workers are developed and as psychiatrists work on teams with other professionals, they may find themselves in charge of the other workers without knowing anything about their training, background, or abilities. A supervisor who is aware of clinical issues and is flexible in his expectations will be able to work more effectively under those conditions. Under the new plan, the resident will supervise community workers, mental health workers, and social work students, all of whom have clinical responsibilities on the team. The resident’s supervisory skills will be evaluated during his weekly meeting with the team’s medical director. Administrative skills are difficult for some psychiatrists to learn, as they often have difficulty changing from semi-passive listeners to active bosses. Under the new plan, the residents will work with the medical director and team leaders to understand the day-today problems of dealing with the system. A didactic program dealing with the application of systems theories within a community mental health center will be instituted; each resident will have to attend. The most difficult and nebulous portion of the new curriculum is the area of community consultation. Center staff discussed the pros and cons of having the residents become involved in community consultation. The nonpsychiatrists seemed to feel that the residents would disturb a delicate balance of center and community and destroy the careful work that had preceded them. Most psychiatrists, however, seem to interact tactfully with the community. The center staff helped design a method for teaching consultative skills to the residents; it will include research on broad psychosocial issues as well as actual consultation in the community. Community consultation will begin in the second year, when the resident will be in the clinic one-half day each week, and will grow until it becomes an important part of his more intensive third-year experience. A resident’s education in community psychiatry must be designed to be relevant to his future, not simply to meet current service needs. Perhaps there are other skills besides administration, supervision, and community consultation that should be included. Training in such areas as emergency consultation, brief psychotherapy, intake, or triage should not be excluded. The emphasis, however, should be on the resident’s learning to do what he will be doing after graduation, not what other team members will do as part of their role-specific tasks.S
Ethical Issues in Community Psychiatry
DAVID I. JOSEPH, M.D. Faculty Member Psychiatric Residency Training Program Overholser Training and Research Division ROGER PEELE, M.D. Assistant Superintendent St. Elizabeths Hospital Washington, D.C. In
delivering
chiatry
mental
operates
community between
health
under
and the the provider
organization
services,
two contracts: provider of services
requesting
them.
community
psy-
one between
the
of services and and the individual
one or
Each party in the con-
tract has a system of ethics and values that determines its conception of what services should be available and how they should be delivered. Often there are conflicts. Using case studies from a community mental health center, the authors discuss many of the conflicts and ways of resolving them. SThe have years.
sociopolitical and ethical received increased attention As one branch of medicine
aspects of medicine during the last 25 more often concerned
Dr. Josephs mailing address is St. Elizabeths Hospital, Washington, D.C. 20032. He also is clinical instructor and Dr. Peele is clinical associate professor in the department of psychiatry and behavioral science at George Washington University in Washington, D.C.
VOLUME
26
NUMBER
5 MAY
1975
295
with the quality of life than with its preservation, psychiatry has felt and has been strongly influenced by these ethical and political forces. Community psychiatry, with its mandate of comprehensiveness and continuity and its direct relationship to both the community as a whole and to the individual seeking assistance, has been a frequent battleground for these forces. Some of the ethical issues in community psychiatry can be illustrated by the case history of Peggy, a 17year-old, single, unemployed girl. Peggy had been in and out of psychiatric hospitals for several years. Her conflicts with her parents had escalated to the point that the court declared her to be beyond parental control. She was admitted to a community mental health center by court order, to be kept there until suitable housing could be found. Two years before admission to the center Peggy had a baby. She planned to give the child up for adoption, but changed her mind at the time of delivery and kept the child, who was being reared by her parents. Shortly after admission it was discovered that Peggy was eight weeks pregnant. She was afraid she would repeat her earlier experience and, after considering other courses of action, requested an abortion. Her parents, however, strongly objected on religious grounds. The center was faced with the decision of whose rights and wishes to support; those of the patient who desired and whose mental health dictated an abortion, or those of the nonpatient clients, the parents, who were residents of the community and were legally responsible for the patient. This case and others we will discuss involve the areas of representation, responsibility, and accountability, as well as morality, personal values, and other traditional ethical concerns. By examining these areas in greater detail, we hope to elucidate a common perspective for approaching ethical issues in community psychiatry. Our views of the ethical issues in community psychiatry grow out of our experience in a community mental health center. Although a center is but one variant of community psychiatry, its comprehensiveness and continuity, called doing everything forever,’ “ ensure that ethical issues will be raised, often with painful directness.2 In our view, the primary task of community psychiatry is the provision and delivery of mental health services to a specified community. It involves two contracts: one between the community as a whole and the provider of services, and another between the provider of services and the individual or organization requesting them. Although such contracts are specifically concerned with the types of services and the manner of their delivery, they are, in fact, based on fundamental ethical principles. Each party has a value system and has strong feelings about its essential correctness. Such ‘ ‘
‘A. F. Pauzetta, Community Mental Lea & Febiger, Philadelphia, 1971. 2 L. J. West, “Ethical Psychiatry
American
296
Journal
of Psychiatry,
HOSPITAL
Vol.
126,
Health: and
Myth
Biosocial
August
& COMMUNITY
1969,
and
Reality,
Humanism,” pp.
226-230.
PSYCHIATRY
a value system, however, is usually taken for granted or is obscured by the more measurable, quantifiable aspects of the contract. Neglect of this aspect of cornmunity psychiatry, and its implications for the relationships between the relevant parties, contributes significantly to the confusing and often heated transactions that one so often encounters. The values underlying any psychiatric system play a major role in determining the types of services offered, the priority of each, and the manner in which each is delivered. We propose that ethics, as they pertain to the delivery of mental health services, should not focus on what is right or wrong in absolute terms, but rather consider for whom it is right and for whom it is wrong. The concept that each party participating in the contract has his or her own values is consistent with a systems approach to such transactions.3 This framework devotes particular attention to the individual components of the system and the nature of their interactions, increasing the opportunity for developing mutuality and what Deutsch has called productive conflict.4 We feel the individuals and agencies of a cornmunity must retain their own values and wishes. Therefore, we have considerable theoretical and practical difficulty with the concept of putting the cornmunity on the couch and treating it as a single unit. In focusing on the delivery of mental health services to a specified community, our definition of community psychiatry resembles many others. It differs from most, however, in that it is not tied to a theory, concept, or body of knowledge and does not specify the goals of the community services. Important as certain tasks, goals, or bodies of knowledge are, they should not be built into the definition of the discipline of community psychiatry. It ought to be defined solely in terms of responsibility to a given community. The theories, knowledge, tasks, and goals that are used in fulfilling that responsibility will vary according to the practitioner of community psychiatry and the community he serves. THE
TWO
CONTRACTS
Many of the ethical issues confronting the community psychiatrist can be understood as growing out of attempts by the patient, the family, the psychiatrist, and the community to define the task of the community mental health center in different ways. Some of the resulting confusion can be reduced by keeping in mind that the center is involved in two separate contracts, each based on a different set of values. In deciding the terms of the contract between the center and the community, it is necessary to consider what is best for the community as a whole. Thus the center and the community may decide to employ their 2 E.
M. Miller
and
A. K. Rice,
Systems
London, 1967. M. Deutsch, “Conflicts: Productive Social Issues, Vol. 25, January 1969,
of Organization, and pp.
Destructive,” 7-41.
Tavistock, Journal
of
Individuals receiving care in a center ought to have the same rights, within the limits of the contract with the community, as those receiving care from the private sector. resources in the treatment of alcoholics, addicts, and psychotics, and devote less attention to individuals with neurotic or characterological problems. Or they may decide that the center will offer only short-term psychotherapy to outpatients. The exact nature of the contract will depend on the characteristics of the community, the resources available to the center, and the interests and professional perspectives of those who set policy. The contract between the center and the individual seeking treatment or the organization wishing consultation is based on a different value system. We feel that, under this contract, the center operates on the same ethical principles as does the private psychiatrist. Such principles emphasize the rights and wishes of the individual, giving far less consideration to the rights and preferences of the community. Individuals receiving care in a center ought to have the same rights, within the limits of the contract with the community, as those receiving care from the private sector. To accord them less would be ethically indefensible and would radically alter the quality of care delivered. Furthermore, in most instances the initial contract between the community and the center is based on the community’s insistence that quality psychiatric care be available to its members, a goal that is best met by following the strict guidelines that operate in the private sector. Since the wishes of the individual patient and those of the community as a whole are often conflicting, the center that operates according to such principles may often find itself at odds with the community. Failure to support the individual’s rights and wishes not only deprives that individual but also erodes the quality of care delivered to the community. Peggy’s case clearly illustrates a conflict. Her wish for an abortion was in direct opposition to her parents’ wishes. Since we see the center operating as the patient’s agent, we elected to support the patient’s wishes. Peggy appealed to the legal system to decide whether or not a minor could have an abortion over the objections of her parents. The court ruled in Peggy’s favor; she had an abortion, and she was placed in a facility for adolescent girls. As individuals we provide mental health services from the tradition and perspective of the doctor-patient relationship, the therapeutic alliance. But the
relationship between the community mental health center and the community differs greatly from the model with which many of us grew up professionally and with which we are so comfortable. The contract between the center and the community permits the center to provide direct mental health services not available through other facilities in the community and to make consultation available to organizations requesting it. Many problems arise, not so much from difficulties in deciding what services are to be rendered but in deciding which system in the community should provide that service. The center is continually under pressure from multipie sources in the community to define itself as something other than a treatment facility: to become a detention home for juvenile delinquents, a nursing home for the elderly, or a boarding home for indigent citizens with psychiatric problems. Conversely the center may try to redefine the school as a treatment facility, the nursing home as a geropsychiatric center, and the courts and the legal system as a therapeutic resource for disturbed adolescents with severe behavior problems. The center’s effectiveness depends in great part on its ability to determine what it can and cannot do, and to state clearly what services it can, cannot, or will not provide. Tempting though it may be, the center must not get caught up in the omnipotent notion that it can answer all the needs of the community or that all human needs fall within the general purview of mental health. The same clarity of purpose must be forthcoming from other institutions in the community. Without such clarifications, the center and those institutions may repeatedly find that they or others believe they have failed to carry out their mandate. OTHER
ETHICAL
ISSUES
The following cases exemplify other ethical issues in community psychiatry. Dale, a 14-year-old boy, was referred to the center by his mother and his school because of his unmanageable, hostile, and aggressive behavior. His difficulties stemmed in part from a congenital hip disorder that went undiagnosed for nine years. The disorder gave him an awkward gait, which was the cause of many jokes. When he was nine he underwent surgery, was in a cast for many months, and was out of school for a year. During that time he received individual tutoring. When his rehabilitation was complete, Dale returned to school but did poorly; he resented the absence of individual attention and frequently got into fights with his classmates. Finally, in desperation, he was brought to the center. His mother was informed at the outset that her son’s treatment would require that she also be involved in treatment. Although she agreed initially, she refused to keep appointments, even after being told that her failure to participate would lead to her son’s discharge. Dale also had difficulty participating in the program. The contract between the center and the community
VOLUME
26
NUMBER
5 MAY
1975
297
specified that the center be a treatment center. Dale and his mother came to the center requesting treatment, and their contract with the center required their active participation. When Dale’s mother refused to participate in the treatment, she broke the contract, and Dale was discharged. As treatment without his mother’s participation would have been nonproductive, retaining Dale on the rolls would have meant that the center was not providing treatment and was not upholding its contract with the community. Thus although the community was faced with the problem of dealing with a difficult adolescent, its wish for the center to be a treatment center was supported. Mrs. W was admitted to the inpatient service with severe depression. Because she had abused her children, the protective services agency was involved in her case. After several weeks she appeared well enough to be treated on an outpatient basis. The protective services agency was afraid she would again abuse her children, and urged the center to delay her discharge from the inpatient service. Should the center act as the agent of the patient, her children, or the protective services agency? The center understood and respected the fears of the agency and was concerned about the welfare of Mrs. W’s children. However, the task of the center was to provide evaluation and appropriate treatment for the patient. Since she no longer required inpatient care, she left the hospital and returned for outpatient treatment. The agency was informed of this course of action, and they handled problems involving the care of Mrs. W’s children. FURTHER
CONTRACTUAL
PROBLEMS
Many conflicts between the center and the community revolve around problems of the young and the old. A woman brought her 72-year-old mother, Mrs. B, to the center with the complaint that she couldn’t care for her any more. She said, My father died a year ago, and since then my mother has been wandering around at night, confused and unable to care for herself. My apartment is too small for her to live with me. Mrs. B was admitted to the ward, and her daughter offered minimal cooperation in the evaluation, treatment, and long-range planning for her mother. Mrs. B was found to be severely depressed; however, she responded to treatment and soon was able to live outside the hospital. Once evaluation and treatment are completed, what is the responsibility of the center to the patient? Does the center have the right to refuse to define itself as a nursing facility for geriatrics and throw the patient out, leaving the family and the community to provide proper services for the care of its elderly? Sally, a 15-year-old girl, was admitted from a large institution for adolescents where she had made frequent runaway attempts and suicidal gestures. After several months she was well enough to leave the hospital, but she had no place to go. Her mother, a “
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298
HOSPITAL
& COMMUNITY
PSYCHIATRY
paranoid schizophrenic, had severely abused her children. Sally and her brothers and sisters had been made wards of the court and the welfare department, but there was no facility that would accept a girl her age with her history. Although she no longer needed hospitalization, she was making the hospital her home. Furthermore, the welfare department insisted that it had a right to reject any placement the center might find for her. Should Sally be discharged and the cornmunity be forced to grapple with the problem of the adolescent with no place to live? If the center fails to discharge Mrs. B or Sally, it violates its contract with the community and becomes, for these two individuals, a nursing home for the elderly and a residential boarding home for adolescents. Such action diverts badly needed resources from patients who require inpatient psychiatric evaluation and treatment. Furthermore, since the community mental health center is structured to be a treatment center, it performs poorly as a home. Finally, if the center agrees to provide shelter for these individuals, it colludes with the community’s failure to provide more appropriate facilities for them. lf feelings did not interfere with judgment, a course of action would be clear; Mrs. B’s daughter would be informed of her mother’s discharge and the provision of care would become her responsibility. The welfare department would be informed of Sally’s discharge and would become responsible for finding a place for her to live. The hope was that after the same process was repeated with similar individuals, the community would realize that the center would not allow itself to be converted into something other ‘than a treatment center, and would build the necessary facilities. It was the spectre of sacrificing Mrs. B for the longrange benefit of other Mrs. Bs, or of abandoning Sally for the benefit of other Sallys, that prevented us from discharging both. Thus Mrs. B remained as an inpatient until an adequate foster home was located, and Sally lived in the hospital until the welfare department was pressured by the courts to agree to pay for lodging at a halfway house. We realize that our course of action regarding Mrs. B and Sally represents obvious inconsistencies. Theoretically and contractually each should have been discharged. These cases are included, however, to empha-
Once evaluation and treatment are completed, what is the center’s responsibility to the patient? Does it have the right to refuse to define itself as a nursing facility for geriatrics and throw the patient out?
size that the center too may often find it difficult to adhere to its contracts. Many times patients try to define the center in their own terms. Mrs. S, a 72-year-old woman with a history of recurrent psychotic depressions, was ready to be discharged from the hospital. She had no family, had a limited monthly income from Social Security, and had a meager wardrobe. She did not want to leave the hospital, where she felt that she had better lodging, more opportunities for socialization, and better medical supervision than she could afford elsewhere. What right does the center have to insist that it is not a boarding home and force her to take any lodging she can afford? Mr. P was a 36-year-old chronic alcoholic who repeatedly presented himself in the emergency room when intoxicated. He was admitted and dried out, but he refused to participate in any therapy. He often had visitors bring alcohol onto the ward. He expressed a wish to withdraw from alcohol and to remain in the hospital, but showed no motivation to change. Should he be allowed to stay? While sympathetic to Mrs. S’s wish to remain in the hospital, we informed her that on a certain date she would be discharged. We assisted her in a search for housing, and before her scheduled discharge she moved to an acceptable, though scarcely ideal, boarding house. Mr. P was discharged because of his drinking on the ward. To have retained him as an inpatient would have continued wasteful use of the hospital’s resources. Mr. P was told that if he wanted treatment he could return and be readmitted. The community mental health center compounds its problems and those of the patient by allowing itself to offer services it has not contracted to provide. Spurred by a desire to help the disadvantaged, the center too often stretches its boundaries and allows itself to stray from its proper task. Thus wards become crowded with nonpsychiatric patients, overworked outpatient departments dispense less than adequate care to ensure that everyone gets something, and everyone, including the community, accepts less than ideal treatment for patients. The intense personal struggles and conflicts brought on by maintaining the boundary and adhering to the contract sometimes make it appear easier to give in. But such action compromises the center’s ability to deliver quality care and leads to other difficulties. Ethical questions are usually addressed with great reluctance because they have no absolute answers and because they seem so far removed from the hard data of basic science. Not to evaluate them with the same industry with which we examine other aspects of the delivery of mental health services is to deny the degree to which they influence the types of care delivered and the way it is delivered. To question, to reconsider, and to re-evaluate our value system and its implications will help prevent patients from being seen as mere symptoms. Our work will thus be conceived as involving more than the delivery of services to a consumer and will be viewed in the broader context of individual dignity and the social values of an entire community.
Patient
Rehabilitation Through Hospital Work Under Fair Labor Standards DANIEL SAFIER, M.A. Director of Rehabilitation Services RUTH BARNUM, M.A. Rehabilitation Counselor Binghamton (N. Y.) Psychiatric Center
Payment
of patients
for hospital
become a matter of stitutions since the the Department amendments to the
work
assignments
has
great concern for mental health in1973 federal court ruling requiring of Labor to enforce the 1966 Fair Labor Standards Act. A work
program in compliance with Fair Labor Standards has been operating at Binghamton (N.Y.) Psychiatric Center since 1971 Certificates from the labor depart.
ment permit the hospital to pay less than the minimum wage for patients in occupational training or in sheltered employment in a regular job. The authors believe that work therapy has important clinical and rehabilitative functions, and that patients should not be
denied court
the
opportunity
for
such
work
because
of the
ruling.
Under a federal court ruling issued in late 1973, the Department of Labor is required to enforce provisions of the Fair Labor Standards Act regarding payment of S
Mr. Safler’s New York
address 13901.
VOLUME26NUMBER5
at the center
MAY
is 425
1975
Robinson
Street,
Binghamton,
299
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