Dilemma not resolved

I just got back from session, worked up instead of feeling better. I'm working at a board and care facility for disabled adults with psychotic disorders. A resident ended up in a locked unit against her will after a series of sloppy and careless moves that involved different entities having power struggles with each other instead of caring about the resident, who frankly did not meet the legal requirements to be held against her will.

I was really bothered by the whole thing, every aspect of it, and felt like I would have to face a conflict when she got back about how to be genuine with her but not really allowed to say how wrong I thought things were and how badly I thought she was treated.

I expressed this in session since we are strongly encouraged to use our personal therapy for things that come up while being an intern. Also I am not sure that I would want to raise this with my supervisor since he has a very distant approach and I am also not sure if our relationship is confidential.

My therapist compared my experience to his experience as a resident in a locked ward. He seems to think that drawing this parallel somehow helps. He ended up just saying that with these "lifers" as he called them, this would be one of my challenges, to handle the fact that they no longer have autonomy.

I don't feel like anything got resolved. In fact, I feel worse. One of the things that has been happening is that I feel a divide between the clients and how the "system" treats them, and I am clearly aligned on the side of the clients. When my own therapist starts feeling like he is also aligned with the "system" I start to feel very alone and demoralized.

I'm sorry you are struggling with this right now. I remember the conflict between my ideals and the way the system actually worked was (and still is) a huge stressor for me. It's tough with cases where everyone in power had put the person into one box, and refuses to think outside that box... one of the hardest things to come to terms with is how burnt out and jaded people can become after several years. It's the biggest battle I constantly have with myself: to not become jaded...

Can you tell your t how invalidating his response feels? It sounds like he's trying to normalize something you want him to understand is disturbing...

I'm so sorry this all sounds very traumatic, and I'm not sure that the comparison that your T made is appropriate. I have PTSD because I was held against my will. The experience could have been severely traumatic for the client, and is not tantamount to being shut in a care facility, especially if your client was trying to find away to escape. I would say that her distress level as a result of the situation is the most important thing, and your distress about being forced to be complicit in such a situation is also critical, and should be recognized. The fact that people in the mental health care system want to force T's to just accept things like this as part of the system really pisses me off. Things like this can retraumatize a client, and therapists should have no allegiance to anyone but their client. The only thing that should ever be accepted as treatment is that which fits the definition of care. All other acts should be suspect and actionable.

If you are at all interested in thinking about the institution context in which you work though another sort of lens I strongly suggest Michel Foucault's Madness and Civilization if you have never read it. Madness and Civilization - Wikipedia, the free encyclopedia

Wow. "Lifers" to me seems so derogatory, especially when you're saying that the patient you dealt with actually did NOT meet criteria to be locked up?

I'm sorry, it sounds like an awful situation. I don't do well in those types of situations (where you believe or know one thing, but your work environment prevents you from speaking honestly about it). T and I actually were talking about this last week (!) in a different context, how crazy making it can be when work demands that you deny reality

I hope you can talk with your T more about this, so that he understands how you reacted to his statements... and I hope he can be a bit more understanding next time around!

Oh, and THANK YOU. Sincerely, thank you for seeing the patient's perspective, and for caring, and for doing this work.

Thanks for your support and understanding. I'm painfully aware of how bad the system can be. One friend with schizophrenia was so badly mishandled by a whole range of people in the system that he was released without adequate support or follow up, had a command hallucination and poured turpentine on himself and lit himself on fire.

People are extraordinarily vulnerable and powerless in these situations. Many lack an ongoing therapeutic situation that might not only help them but also protect them during periods when "the system" overreaches and has great potential to do harm.

The client as is the case with all the people I work with do not have someone like that in their lives. Psychotic disorders are treated by medications and people pretty much give up on therapy. Basic maintenance is really all they get. It sucks.

If the client who was take away had had a therapist who could have stepped in and protected her or at least overseen the transfer of all these different agencies and entities that got involved conflictually about her, she at least would have had that reassurance.

I did text my therapist to see if he was willing to address the fact that I felt stirred up. He tried to explain that he was trying to give me his experience of how "systems" work. He just told me to continue to talk to him about this. It was at least a response and on a Friday evening I can't really ask for much more, but I don't really feel better. Plus I have to meet with my supervisor on Sunday and I have no idea about whether I should bring this up. It feel raw, like maybe it should still remain with my personal therapist for now.

It is so hard because none of my peers are having to deal with such things so I don't have them to turn to. I don't feel like the staff at the facility really have taken me in yet. They have a way of doing things and it isn't based in therapeutic ideas or interventions. They are understaffed and low paid with no one having a license or any extensive training. They do what they can, and try to be well-meaning, but even my supervisor says that interns like me often come in and start connecting the dots in ways that people haven't seen. And have more complex understandings and tools than the workers, but less power so it is a very tricky thing.

I wanted to work with this population and in some ways learn about how community mental health works, but it is painful. I wish that I were licensed and could just take some of these people as real clients having full therapy sessions to break the cycle of them just falling into the cracks over and over.

Have you ever read about the patience's rights movement or Psychiatric survivors movement? Psychiatric survivors movement - Wikipedia, the free encyclopedia
This forum has some echos of that time. Patient only groups became a large and productive part of this movement, and gave people the opportunity to process some of the damages done by institutions with out big brother looking over their shoulder. If you are at all interested in this kind of thing you can PM me, its a research interest of mine.

Unfortunately, thst is the society we live in.... It's to big and greedy for their to be genuine help for those with mental health issues..... You will always just be a wheel in the clog.... But, doing the best you can, even if the results are not what you want is all you can do....

Would it be so bad to tell the resident who was locked up against their will that you thought the situation was poorly handled? Institutions are not monoliths and just because you're staff, you don't have to agree with every decision that gets made. It can be very powerful and healing to hear that someone in a position of (relative) power saw what happened.

Also, what are the mechanisms for incident reporting where you work. Can you flag a situation and trigger a review?

I'm sorry your T responded by basically telling you to get used to it instead of validating that it's horrible watch power being abused like that.

I'm a bit taken aback by your statement that there's no licensed oversight. Every institution I worked in at least needed a clinically licensed individual making decisions and intervening as needed. It's scary enough when you have one overworked clinician in charge. I shudder to think of having no one with any real education or expertise running the show...

I would second the idea of finding a way to get a review of the case... it sounds like a really emotionally difficult environment to work in. I hope you can find the support you are looking for. Sometimes trying to change a broken system, or at least bring light to how broken it is can be the hardest thing in the world... I also hope you have access to good supervision. I don't think there's anything wrong bringing your concerns about this incident to your clinical supervision. You may still not get the support you are looking for, but at least it's another option. Also, do you have access to group supervision? It might be helpful to bring up there as well. I've found that my peers had more open ideas and offered better support at times than my clinical supervisors. They were not yet jaded and hardened by the system... Just a thought.

I'm sorry you've had to experience this and it sounds like the facility you're interning in is not the best introduction into the mental health system. I think you should still tell your T about this before your supervisor (who doesn't sound very good). Your T does sound old school (I've heard the term lifers and chronics to describe patients) so you might need to over stress to him that the language he uses sounds outdated and dismissive. If your T can try to be more empathetic you can use your sessions with him as your unofficial supervision and ask him for direct advice. My pdoc stressed to me not to do my internship in an inpatient setting because it could be too upsetting. I was committed as a 12 year old too 30 years ago and it was traumatic. The system has actually improved, but there are still a lot of problems like you're seeing. When you're licensed you will have a little more power so I think there is a light at the end of the tunnel. It's good exposure for you but unfortunate that it has to be during your training. I know this is your internship but is it possible to leave it and apply for another one not in this type of facility? A T friend of mine did this due to poor supervision.

Thanks for all your support, suggestions, and questions. I'm starting to get some more perspective on this situation. First my therapist did give a fuller response to me, saying that it was a long conversation but in short he is aware that abuses of power have been quite harmful to me and that could lead to lots of empathy for clients. Since it does reach into something personal, I am reluctant to discuss this with my supervisor at this point. I may though bring it up very generally since he has worked for this place in various positions and would perhaps have a larger perspective on how it works. Plus he is licensed and pretty client-centered so he might understand why I would have a different response than the rest of the staff.

The facility is not a locked unit, though it is sorta run as if it were. There is a clinical director who is a licensed social worker, but she oversees every residential unit in this large system of board and care.

To make things more complicated, many of the residents, including the one taken away, are conserved, meaning they have lost a lot of power over what happens to them. Either a coordinator or a conservator calls all the shots. Those people are not at the facility and are not observing the client day to day. The clients often also have special teams that work them, also not on site and called in from outside. That is what happened in this case. People from outside were called in and had power trips with each other, changing what was happening with this client seemingly on a whim and leaving no room for the client to try to cooperate or have a say in any of it. They essentially escalated the situation, making it worse. I think for most of the day the workers at the facility were trying to keep the resident from having to leave, but simply did not have the power to do so and then just were complicit in the whole thing. Still it was wrong. She was not a danger to herself, others, or gravely disabled, the legal requirements for a hold. She was showing some symptoms like being more labile and scattered, but there are so many ways to handle that that would be helpful and supportive instead of dragging her off to not one but two locked units, which in her mind are the equivalent of concentration camps. Of course then it becomes a vicious cycle since she probably became more and more symptomatic due to this treatment. I probably can find a way to let her know that I was concerned about her and felt it was badly handled. I did express dismay while it was happening and talked to the administrator a few times so it wouldn't be a surprise if word got back to them.