Conclusion

Constant awareness—particularly a careful, imaginative awareness— and a sense of personal responsibility play a fundamental role in ensuring that clients have adequate access to the help they need, particularly in times of crisis when the therapist is not immediately available. In hospital and similar organizational settings, the apparent abundance of staff may lead to a diffusion of responsibility in which no one is available to help a patient in crisis. Levenson and Pope (1981), for example, present a case study in which a psychology intern was assigned responsibility to contact promptly a suicidal individual who had been referred to the outpatient unit by the crisis service and arrange for conducting an intake assessment. The intern, however, was absent from the staff meeting at which the assignment was made. His supervisor, also absent from the meeting, had sent him to attend a two-day training session at another institution. During the next few days, the individual committed suicide.

The hospital's thanatology committee concluded that the crisis service had handled the situation appropriately in referring to the outpatient unit. The outpatient unit itself was not involved in the postmortem investigation because, according to the hospital's procedures, outpatient cases are not opened until the potential patient is contacted by the outpatient unit for an intake screening. The intern himself struggled with his reactions to these events. Among his conclusions was that he had "at some level internalized the organizational view that no one is really responsible" (p. 485).

Imagination is useful in creating an awareness of the types of crises a client might experience and what difficulties he or she might experience in trying to gain timely access to needed resources. The scenarios for discussion presented at the end of this chapter provide examples.

Thinking things through on a worst-possible-case basis can help the therapist to anticipate the ways in which Murphy's law can make itself felt in human endeavors. If we look back from that imaginative perspective, we can ask ourselves: If any of the worst possible case outcomes had happened, what, if anything, do we wish we would have done to prevent them, lessen their impact, or prepare for addressing these events?

No therapist is infallible. The most careful and confident assessment of a patient's potential for crisis can go awry for any number of reasons. But the therapist should take into account his or her own fallibility and plan for the unexpected.

Similarly, imaginative approaches can create accessibility to needed resources. For example, a therapist was treating an extremely isolated, anxious, and troubled young woman pro bono because of the client's lack of money. From time to time, the client became overwhelmed by anxiety and was acutely suicidal. However, she had no practical access to hospitalization because of her financial status and the absence in the community of sufficient beds for those who lacked adequate funds or insurance coverage. In similar cases, the therapist had encouraged clients to make arrangements to have a trusted friend come by to stay with the client during periods of extreme dysfunction and suicidal risk. However, this client was so socially isolated that she had no friends, and the therapist was unable to locate an individual—from local church and synagogue groups or from hospital volunteer or-ganizations—who could stay with the client in times of crisis. Determined to come up with some arrangement that would help ensure the client's safety and welfare should the client experience a crisis and the therapist be unavailable, the therapist and client finally hit on the possibility of the client's going to the local hospital's waiting room. (The waiting room adjacent to the emergency room was open around the clock.) The therapist contacted hospital personnel to make sure that they would have no objection to her patient showing up at odd hours to sit for indefinite periods of time in the waiting room.

The arrangement worked well during the remaining course of therapy. According to the client, simply knowing that there was someplace for her to go frequently helped her to avoid becoming completely overwhelmed by external events or by her own feelings. On those occasions when she did feel that she was in crisis and at risk for taking her own life, she found that going to the hospital waiting room seemed helpful; it made her feel more active and aware that she was doing something for herself. Being out of her rather depressing and claustrophobic apartment, sitting in a "clean, well-lighted place," and being around other people (who, because they were strangers, would be unlikely to make, in her words, "demands" on her) were all factors that helped her feel better. Knowing that there were health care professionals nearby (even though she had no contact with them) who could intervene should her impulses to take her own life become too much for her, and aware that she was carrying out a "treatment plan" that she and her therapist had developed together, helped her to feel calmer, less isolated, and comforted in crisis. The waiting room strategy enabled this highly suicidal client to be treated safely, although hospitalization was not feasible, during the initial period of therapy when outpatient treatment alone seemed, in the judgment of both the therapist and an independent consultant, inadequate and when the client could not afford additional resources. It made imaginative use of resources that were readily available in the community and were accessible to the client.

Understanding the degree to which individual clinicians and mental health organizations will be accessible and will make help available is a crucial aspect of the patient's informed consent, the focus of the following chapter.

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