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Self Determination

What happens if a client's refusal for intervention affect the lives of others?

Brief Case

Bala (52 years old) stays with a flat-mate Raju (58 years old) in a rental flat. Bala is diagnosed with bipolar disorder and antisocial personality disorder, but he has been irregular with his treatment. He has been unemployed for many years and has a strained relationship with his family. Max, Bala’s Social Worker at the Family Service Centre, provides casework support, food ration and applies for $250 per month from the SSO for Bala’s sustenance.

Max hears from Raju that Bala also sells his sleeping tablets and would frequently demand money from Raju to finance his drinking and smoking habits. Raju added that Bala frequently refused to sleep at night and is occasionally verbally abusive when drunk. This has led to frequent quarrels between the flatmates. Raju had pleaded with Max to admit Bala into IMH for treatment and to find another accommodation for Bala thereafter, but requested for anonymity. Max however knows Bala will not admit to drinking and does not think he needs treatment from IMH.

What are the ethical considerations here?

Responses by social workers:

When I was a fresh Social Worker, respecting client's self determination is one of the commonly misunderstood and misapplied ethical practices. No doubt that Social Workers affirms the right of our clients to make their own decisions, the need to be mindful and knowledgeable on the Code of Ethics is important and it comes into place where Social Worker needs to know when to draw the line.

With the Code of Ethics, it guides us through when we meet with tricky situations and our roles being challenged.

According to the Code of Ethics, "Social workers affirm the right to client self determination which needs to be preceded by ensuring that the client is both aware of and has assessed alternative options. The role of social workers in this instance is to provide all relevant information that would allow the client to make an informed decision." In application to this case scenario, Bala seems not being able to exercise rightful self determination as he is coupled with mental health issues and the irregularity of medicine taking is a concern to his personal well being.

After hearing from his flatmate, Raju, there seems to display a certain level of violence risk between Bala and Raju in times where Bala gets drunk and is mentally unstable. With reference to another Code of Ethics, "Social workers limit the rights to self-determination where in the social worker's professional judgment, clients' actions or potential actions pose a serious, foreseeable and imminent risk to themselves and others." With that, there is evidence to prove that Bala is in need of treatment so that his mental health issue can be managed and a proper assessment can be done to deem his suitability in living in the community.

In this case, the need to protect Raju's identity is necessary. This is because to prevent further conflicts between both of them and also empathizing on Raju's vulnerable situation.

Knowing that Bala would not admit to drinking and does not see the need for IMH intervention, Max would need to seek advice from the Medical team/ Community Health Care Team of IMH to further ascertain on the next step when working with involuntary clients. Since Bala is already known to IMH, the follow up act (Eg, home visit) of bringing him back "into system" can be seen as just providing him with concern and support for a start.

To sum up, Social Workers need to constantly reflect their thoughts and doings in accordance to the Code of Ethics so that timely intervention can be provided to client.

Esther Ng

Social Worker
Sengkang FSC

Commentary

By Dr Terence Yow, Deputy Director, AMKFSC Community Services Ltd.

Disputes among co-tenents, living in rental flats are common problems presented to Social Workers working in Family Service Centres. There are several ethical considerations that Social Workers such as Max, may be facing in the short case-study above.

In addressing ethical dilemmas, Social Workers needs to base their decision making upon Social Work values, principles, theories, concepts and knowledge to guide their practice and decision making. Though “Reamer’s guide to ethical decision making” may provide some suggestions to how Social Worker may address ethical dilemma, some may find it a challenge in applying it towards working with persons with mental illnesses.

A common question asked by many Social Workers is whether a person who may be mentally unwell is seen to be capable of self-determination and what can be done if the person refuses treatment. Medication and treatment compliance is often perceived by society to be in the best interest of the person with mental illness. Perhaps, if help can be rendered to ensure Bala’s medication compliance he would be able to function better and his conflict with Raju could be minimized. However, one often may sometime focus too much on the label of mental illness and may negate the personhood of the client.

Reamer suggested one Person’s Right to Self-Determination supersedes that same person’s right to well-being. It is important to recognize that Persons with mental illness have rights to self-determine and to plan for or refuse treatment even when it is societally seen to be not in the person’s best interest (unless the person is seen to be of harm to oneself or others). To impose treatment or to place persons with mental illness in an institution against their will, takes away their rights to self-determination and could further marginalize and disempower them. Hence, in many countries such as United States and even Singapore, treatment cannot be imposed against the will of persons with mental illness, unless they are assessed to be of harm to oneself or others.

However, an additional complexity may arise where Bala’s mental health condition and addiction may have caused distress to his flatmate, Raju, who may have felt intimated to give money to Bala, and his sleep being affected in the process. Here, Reamer suggested that one person’s right to well-being (Raju) supersedes another person’s right to self-determination (Bala). Very often, Social Workers often have to struggle with what constitutes well-being and if safeguarding Raju’s well-being may compromise the well-being of Bala in the process. These conditions however do not justify that one can forcefully enforce treatment or place Bala into an institution, against his will, but suggest the need for the Social Worker to look into the issues that Raju is facing, in view of Bala’s possible non-compliance.

Social Workers are sometimes triangulated with information provided where the person do not wish to be identified as the information provider. New Social Workers may be influenced by the information provided and may struggle with how they make use of the added information. Upon hearing from Raju that Bala may be using financial assistance received for finance his drinking problem and may be trading off his medication, Max may struggle with what to do with regard to the extension of Bala’s financial assistance and whether to whistle-blow to the psychiatrist on what he heard about the medication. Without evidences, these accounts provided remain subjective and unverified. Being able to verify these information with the client (Bala) requires skills and tact, and the Social Worker may not be able to illicit these information if Raju refused to be associated as the person providing the information. In sharing the difficulty with Raju on difficulties for the worker to verify the information, Max could try to engage and encourage Bala to share with Raju about his concerns on what is happening.

Ideally, the Social Worker should seek to understand the situation from both Raju and Bala’s perspective and should attempt to mediate between the two to arrive at an amicable and positive solution for both of them. The Social Worker in providing mediation, facilitates an interaction which allows the two to speak directly to each other on their concerns, listen to each other’s perspective, to seek clarify and to arrive at an outcome which they are prepared to accept.