Wave of Consciousness, "A Voice of Sanity in a World of Conflict"

When Patients Quit

by Natalia J. Garland, M.S.W.

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 deteriorated.*

When patients 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.

The medical 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 seek care.

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 more.

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)