There is a richness that exists in social work which is not
so apparent in other professions: we do outreach and we follow
up on our patients. We do not lightly accept the disappearance
of a patient from our caseload. We know that when a patient
quits before completion of treatment, it can mean that the
mental health of the patient will deteriorate or already has
miss appointments, we start making phone calls and sending
letters to try to encourage them to return to therapy, and to
assess if they need crisis or emergency care. We do not close
a case without documenting our efforts to locate the
individual. When a patient successfully finishes therapy, we
often do aftercare tracking to ensure they are still stable
and not in need of support.
profession does not seem to do this. If you do not keep an
appointment with your doctor, he probably will not contact you
out of concern for your condition. He probably will not
follow up to make sure you are taking your medication and that
you are getting well. If you need more medication, or if your
condition gets worse, it is entirely your responsibility to
In terms of a
holistic approach to health, the medical model is not ideal.
Self-care might be the last item on your list of priorities.
There are so many other obligations in daily living. Having
to call the doctor's office and then wait a few days before
you can get an appointment can be daunting. Keeping the
appointment can mean taking a day off work, getting yourself
to the doctor's office when you are feeling too sick to drive,
and then sitting in the doctor's waiting room for an hour or
I wonder what
it would be like if doctors made outreach phone calls.
Perhaps we would feel like we were really cared about. Maybe
we would be more motivated to take better care of our health.
(In my lifetime, I have had two dentists whose secretaries
called to check on me after extensive dental work.)
When any of my
patients stop keeping appointments, I become very concerned
and I take action with phone calls and letters. In response
to my outreach, some will return to treatment. Some will tell
me that they were touched by the courtesy and respect. And,
some I will never see again.
The loss of a
patient is where doctors have an advantage over social
workers. Doctors seem to learn that they will lose some
patients. Not every heart patient will survive surgery. The
doctor is not expected to save everyone. Do social workers
seem less prepared for patient attrition or untimely death?
I learned a lot
in graduate school and I loved most of my teachers, but I do
not remember anyone talking to me about the number of losses
I might encounter. Professors seemed to focus on teaching the
skills of helping. I do not remember any discussion on
unsuccessful terminations and the impact this might have on
the therapist. Or perhaps it was I who was more focused on
learning the skills of helping. Perhaps in those earlier days
I had yet to feel the accumulated impact of treatment losses.
If you are a
social work student or a beginning professional, let me tip
you off on something which may have been overlooked, for
whatever reasons, in your education. If you are an experienced
professional, let me validate the reality you probably
encounter from time to time.
We are going to
lose some. Some drug addicts are going to take a lethal
overdose. Some alcoholics are going to keep on drinking.
Some psychotic patients are going to stop taking their
medication and end up among the homeless. Some domestic
victims are going to return to their abusive partners. Some
mandated patients are going to commit another crime and serve
more prison time.
It is not
necessarily our fault. It is a truth of human behavior. By
accepting that truth we can create structures that allow us to
process our feelings and reactions, review case dynamics
objectively, learn, and continue providing care for the
patients who are still with us. Social workers are only
human. There are going to be moments when we need to grieve.
[*NOTE: In some
cases, quitting treatment may mean that treatment has been
successfully or adequately completed. The patient may feel
satisfied with his improved functioning and simply not return
to treatment. In court-referred cases, however, quitting
treatment seems often to mean a deterioration of functioning
and, in addition, puts the patient in non-compliance with the
legal mandate. Reaching out to the mandated patient is
essential not only to attempt to re-engage the individual,
but also to document the therapist's concern and efforts.]
(Written 03/03/03 - Revised 12/01/03)
Until we meet