My social service agency is a private mental hospital. Services include inpatient and outpatient treatments for mental illnesses and drug addiction. Much of the status of our clients’ rights and protections are provided by law. Of course, the hospital prioritizes a medical model of treatment. There are 20 psychiatrists, but only five social workers. However, patients do participate somewhat in their own treatment planning. Most are participating voluntarily, although a few patients are committed involuntarily, and their care is overseen by a judge. In addition, the willingness of health insurance to pay for care is a big issue that can limit the availability of treatment, since most patients are unable to pay for hospitalization costs out of pocket.
The formal and informal ways clients participate at the micro level include collaborating with their psychiatrists, requesting appointments with other care providers, requesting transfers to different psychiatrists, finding care elsewhere in the community with or without the help of social workers, finding legal representation, and as mentioned, deciding whether and when to participate in or leave the hospital. Patients talk with each other about the care that is available, so for those psychiatrists who do not refer their patients to other care providers, patients will often take the initiative. Patients can freely choose from various outpatient program schedules. Therapy groups that meet evenings and weekends are very popular, as they allow patients to maintain a regular work schedule while taking part.
Currently, clients at our agency are fairly limited in their ability to participate in or otherwise influence the macro level planning policies and programs at the present time. However, the current popular evening/weekend outpatient programs were actually proposed by clients. After several requests one of the psychiatrists, understanding the stress put on patients from taking off work to attend outpatient therapy, agreed to initiate an evening/weekend program. There are now several psychiatrists who lead these. There is no formal procedure for providing feedback, however, and many psychiatrists still see themselves in an authoritarian role. This is sometimes beneficial; for example, when patient and psychiatrist agree that treatment needs to extend beyond the period recommended by insurance companies, psychiatrists request a doctor-to-doctor phone conference with the insurance company, and will usuallly receive authorization for an extension. Other times their authoritarianism is unwelcome; psychiatrists will go to court to request an extended inpatient stay in the face of opposition from some patients. This request also is usually granted. While this may be necessary, no patient has ever felt empowered by such a move; quite the opposite. Psychiatrists do explain why they resort to enforced commitment. However, obviously the patients do not agree, or they would stay voluntarily.
Some tactics we could use to foster a greater level of inclusion of clients include providing formal methods of feedback, perhaps an exit interview at the end of treatment; establishing patient advisory boards; and increasing social work staffing in order to increase the involvement of social workers to assist patients in accessing community services. I recommend a patient advisory board with assistance from social workers. However, it is important that patient advisory boards have real power and control over their activities and outcomes. They should be on the upper rungs of the participation ladder (Arnstein, 1969). Placating them by giving them a role and then failing to heed their advice would lead to further frustration. However, if we can demonstrate a project that clearly benefits the doctors in addition to the patients, then the board would likely be given more leeway in future projects, and a partnership can be developed.
The major barrier that prevents greater inclusion and sense of ownership among patients is the resistance of psychiatrists to change. Doctors tend to have authoritarian personalities. In addition, their advanced studies leave them feeling that they have exclusive ownership of specialized knowledge. They are unlikely to desire much power sharing with patients as recommended by Levin (2012). However, there is a great deal of information regarding psychiatric and addiction treatments online. The use of appropriate websites, then, would allow patients adequate knowledge for their purposes, when combined with their own life experiences. Suggestions to minimize the barriers to patient involvement include a patient advisory board with a well thought out plan that allows the psychiatrists to perceive the seriousness and level of study of patient advocates who are demanding a greater role.
Therefore, the tool selected from the Community Tool Box website (University of Kansas, 2015) is number 11, Influencing Policy Development, because this can demonstrate to the decision makers the need for and effectiveness of change. When all the steps are in place, this is clearly a well thought out plan that would be difficult to object to without sounding unreasonable. The steps include stating why a policy needs to be developed or modified, studying the issue or problem a policy change would affect, indicating the type and context of policies to be developed, stating what the group will do to influence each of the stages of policy development and the broad goals, listing resources and assets to be used for policy development, indicating potential allies and opponents of policy development efforts, identifying targets and agents of policy change efforts, choosing strategies and action plans, identifying the steps to take, implementing the plan and assessing the results.
These skills could be used to help patients become more participatory by, for example, creating a patient advisory board whose first task is to lengthen the available time for hospital stays without having to appeal to insurance company doctors. The board could assemble the latest research, show how recidivism ultimately costs insurance companies more in the long run; could work with legislators, if insurance companies are resistant; and/or could apply for grants to pay for longer stays on a trial basis. If successful, this would bring the hospital more money with less hassle, saving the doctors time. The board members would develop and demonstrate a sense of self efficacy and empowerment. Once they can demonstrate the pragmatic benefits of such bottom-up participation in policy setting, this would likely cut through doctors’ resistance (Mizrahi, Humphreys, & Torres, 2009). These are all activities that doctors could do themselves, but their time is limited, so hopefully they would grow to appreciate the activities of the board. Then the board would have the power to make further changes.
- Arnstein, S.R. (1969). A ladder of citizen participation. Journal of the American Institute of Planners,
35 (4), 216-224.
- Levin, L. (2012). Towards a revised definition of client collaboration: The knowledge-power-politics
triad. Journal of Social Work Practice, 26 (2), 181-195.
- Mizrahi, T., Lopez Humphreys, M., & Torres, D. (2009). The social construction of client participation:
The evolution and transformation of the role of service recipients in child welfare and mental
disabilities. Journal of Sociology and Social Welfare, 36 (2), 35-61.
- University of Kansas Work Group for Community Health and Development. (2015). Influencing policy
development. Community Tool Box. Retrieved from http://ctb.ku.edu/en/influencing-policy-