Intentional Care Performance Standards

What is Client Choice?

Client choice refers to the right and the power of the adults we work with to make choices for their own lives, to exercise control over their lives, and to be self-determining.

What Happens When People are Denied the Right to Make Choices?

It was once thought that people who were diagnosed with a major mental illness needed professionals to make choices for them. Consequently, most people were confined against their will in mental institutions where personal choice and individual preference were replaced by structured custodial care in which there was little if any freedom to exercise personal choice and preference. For example, everyone ate at the same time, woke up at the same time, had recreation at the same time, went to bed at the same time, lived in the same types of rooms, etc. Sometimes this custodial care model was transferred into the community such that group homes became nothing more than mini-institutions.

Sadly, after decades of making choices for people and controlling their lives in institutions, we learned that denial of personal choice leads to a syndrome called “learned helplessness”. This syndrome is marked by profound depression, apathy, indifference, cognitive deterioration, and a loss of sense of self and self-esteem. Researchers also found that the apathy, depression, cognitive deterioration and loss of self that are the hallmarks of learned helplessness, were perhaps even more disabling than the original mental illness. We now know that denying people the opportunity to make choices results in harming people rather than helping them as was once thought.

Why we value client choice

The Advocates Mental Health Division values client choice because client choice is the cornerstone of the empowerment process. Being able to make personal choices from a range of options that hold the possibility of improving one’s life is what empowerment is all about.

Today we value the concept of client choice because it helps to avoid the devastating syndrome of learned helplessness. We also value client choice because by exercising it people learn about themselves and experience an increase in self-esteem. People learn they have and can use their personal power and will. We value client choice because we respect the adults we work with. We honor their autonomy and efforts to be in charge of their own lives.

Finally, we value client choice because without it, direct service workers could not do their jobs. Client choice drives and shapes the work we do. That is, when clients inform us of their choices, preferences, aspirations and goals, our job is to support them in building the skills and accessing the resources to achieve those goals.

The Dignity of Risk and the Right to Failure

Standard 1

All people learn through a process of trial and error. We learn through taking risks and trying new things. We learn through our mistakes. Most of us take a long, long time to learn from our mistakes and tend to make the same mistakes over and over again. Most of us, at some time in our lives, have exercised poor judgment. We can all think of times when we have made poor choices, self defeating choices, and/or choices which our parents, friends or spouses warned us not to make.

The same is true for people who have been diagnosed with mental illness. Not all of their choices are “crazy”. Just like you, people with psychiatric diagnoses can also make self defeating choices, poor choices and can exercise poor judgment.

Yet just as Elizabeth Taylor has failed^th marriage and not a single casemanager has jumped in to control her “marriage impulse”, so too do people with psychiatric disabilities claim the right to make mistakes, to learn through failures and to take risks. The reclaiming of these rights is referred to as the dignity of risk and the right to failure.

How to implement this performance standard

During supervision direct service workers will demonstrate that they understand the concept of the dignity of risk and the right to failure by being able to give examples from their own lives, the lives of people they work with and/or the lives of people they know.

During supervision and staff meetings direct service workers will demonstrate the skill of questioning whether a client’s choice reflects the dignity of risk and the right to failure.
The direct service worker will demonstrate the skill to resist “pathologizing” client choice i.e. automatically assuming a “bad choice” or a “poor judgment” is due to mental illness.

Direct Service Workers are Advocates of Client Choice

Standard 2

Direct service workers are advocates of client choice. As an advocate of the choices a client has made, a direct service worker may find themselves in a difficult position when an outside third party (such as parents, county or state staff, case managers, representative payees, etc.) demand that client choice be ignored, overturned or undermined. In such situations it is not unusual for direct service workers to feel stuck between powerful and conflicting demands i.e., the mandate to support client choice and the intention of a third party to override client choice. Examples of such situations might include:

· A representative payee withholding a client’s money unless the client shaves and gets a haircut

· A parent ordering a direct service worker to stop a client from applying for a drivers license

· A case manager visiting a client’s apartment and telling the direct service worker, “Get curtains up in this apartment right away and I’ll be back to check on it tomorrow”

· County or state staff making the decision to override the client’s choice of wanting to live in his/her current apartment, by ordering that the client be transferred to a new program because they were not getting along with their roommate and causing “trouble”

How to implement this performance standard

Direct service workers will attend any available in-service trainings on building effective communication skills.

While in the role of advocate for client choices, direct service workers will demonstrate skill in speaking to the third party with respect. This can be accomplished by:

	Listening to the third party’s request without interrupting;
	Repeating the request back to the third party to demonstrate accuracy in understanding the request i.e., “Let me make sure I understand your point. You want “X” to do...”
	Refrain from attacking the third party for being too controlling, etc.
	In supervision, try to put yourself in the “shoes” of concerned parents or county or state staff in order to grow in your understanding of their viewpoint.

When possible, direct service workers will demonstrate skill in deferring immediate demands for action by a third party. After listening and demonstrating an understanding of the request that is being made, the direct service worker is encouraged to say, “Thanks for your input. Let me talk it over with my supervisor. I’ll have my supervisor get back in touch with you”.

During a treatment planning team a direct service worker in the role of advocate of client choice is encouraged to say, “I can see your point and I understand why the group is anxious but I feel uncomfortable with the decision this group is making. I am going to discuss this with my supervisor who will be back in touch with this group”.
Direct service workers will demonstrate skill in bringing all such situations to the attention of the supervisor. Very often it is the supervisor who has the authority to intervene effectively in the situation.

Editor's Note: To protect the rights of Intentional Care, we will only list the remaining standards without providing the Implementation guidelines. Please refer to www.intentionalcare.org for the full guidelines.

We do not Abandon Clients to Suffer the “Natural Consequences” of their Choices

Standard 3

There is a popular belief that includes the notion that people have to “hit bottom” and “suffer the natural consequences of their actions” if they are to ever change their behavior. Given this belief, it is not unusual to hear things such as: “If she refuses to clean then she will suffer the natural consequence of eviction and eventually she will start cleaning” or “If he keeps refusing to go to the dentist he will eventually suffer the natural consequence of losing some teeth and then maybe he will realize he needs to go”.

This kind of thinking has been found to be untrue. Researchers have found that following a disastrous “ natural consequence”, people may change their behavior out of fear, but this change is usually only temporary. Soon after the fear has subsided people revert back to their old behaviors.

People do not usually grow in the wake of disastrous natural consequences. Thus, although we cannot prevent all disastrous natural consequences, we do not rely on them as a means of “teaching people a lesson”.

The Worker is not a Failure if a Client’s Choice Results in Failure

Standard 4

Clients are individuals and, unless they have been declared legally incompetent, are ultimately responsible for their lives and choices. The role of the direct service worker is to support clients in developing the skills and accessing the resources they need in order to actualize their choices and achieve their goals. If clients make self-defeating choices it is not necessarily the workers “fault”. If clients make unwise choices that result in setbacks and failures, this does not automatically mean that the direct service worker has failed. Client and direct service worker are separate individuals. Direct service workers are not expected to run a client’s life.

THE CONFLICTED ZONE:

WHEN CLIENTS MAKE CHOICES THAT APPEAR TO BE SELF DEFEATING OR THAT DIMINISH QUALITY OF LIFE

Standard 5b

There are many times when clients make choices that appear to be self-defeating or which seem to diminish quality of life, but which pose no direct threat to the person’s safety or the safety of others. In such situations the direct service worker may feel conflicted between wanting to “let” clients make their own choices and wanting to protect clients from making self-defeating choices or choices that will diminish quality of life. Examples of such situations include:

· When a client refuses to take medications (especially when medications seems to help)

· When a client is not showering or brushing his/her teeth for long periods of time

· When a client is keeping a dirty (but not unsanitary) room or apartment

· When a client is overspending while trying to live on a fixed income.

· When a client is choosing to spend time with people who seem “undesirable”

· When a client is dropping out of programs/treatment that seemed to help

· When a client is choosing to drink alcohol or use drugs even when contraindicated

· When a client is choosing to have unprotected sexual relations

It is quite appropriate for direct service workers to feel conflicted when they see a client making a self- defeating or “unhealthy” choice. Howeverengaging in conflict by putting yourself at odds with the client is counterproductive and should not be part of the direct service relationship.

THE RISK MANAGEMENT ZONE:

WHEN CLIENT CHOICE BECOMES A SAFETY ISSUE

Standard 5c

There are times when client choice puts the client at risk of being a danger to self in an active way (e.g., suicide) or in a passive way (e.g., refusing necessary surgery), or the client’s choice puts others at risk of significant harm (i.e., a client who is HIV positive having unprotected sex). In such extreme situations it may be necessary to override client choice and intervene in a way that insures safety while also maintaining the dignity of the client.

Risk management is a highly individualized plan aimed at limiting the clients choice in specific areas in order to protect self and others. Such plans are always worked out with the client, direct service worker, supervisor, the treatment team and, if necessary, the human rights committee. Risk management plans also include the specific criteria that a client must demonstrate in order to have a less restrictive treatment plan that restores more personal freedom and choice. For instance a risk management plan for someone with a history of violent assault while intoxicated should include protective measures as well as specific behavioral criteria that need to be achieved in order to graduate to a less restrictive plan.

Supporting Client Choice

DIRECT SERVICE WORKERS DO NOT USE THREATS, COERCION OR BRIBES TO INFLUENCE CLIENT CHOICE

Standard 6a

Advocates Residential Division does not approve of the use of threats, coercion or bribes in order to get clients to choose what we think is best for them. All of these tactics use the power of the direct service worker or professional to force a choice upon a client. All fail to respect the dignity and autonomy of the individual. Examples of such practices that have actually been witnessed in mental health settings include, but are not limited to:

Threatening to leave someone without a ride home if they don’t get in the van immediately (note: verbal and non-verbal cues can be used to threaten/coerce).	An act of power and not respectful of client choice. Use of surprise.
Paying someone to sign a treatment plan	A bribe. Attending to your agenda rather than the client’s agenda.
Talking in technical jargon that sounds intimidating so the person doesn’t understand but says “yes” because they are afraid	Disinformation, and perhaps not adequate information.
Lying to clients i.e., “I’m taking you to the coffee shop” when in fact you are bringing them to the emergency room	Ethical violation, misinformation and surprise.
Not telling clients all of the information they would need to know in order to make a fully informed choice i.e., telling them about rep payee arrangements but failing to mention what one must do to end the rep payee arrangement	Misinformation. Information is power. Failing to give information is disempowering.
Using fear tactics i.e., threatening someone with having to go back to the hospital	Threat and use of power.
Taking away clients' belongings or things they like to do if they don’t comply with what you want	Use of power. Attending to staff agenda rather than the client’s choice. Possibly human rights violation.
Threatening court order or guardianship for not taking medications	Threats, use of power.
Urging a client to do something as a personal favor so the worker doesn’t get into trouble i.e., “Please, as a favor to me, go to your annual physical or I’ll end up in trouble with my supervisors and I could get fired.”	Attending to your agenda rather than the client’s agenda/choice.
Threatening someone with getting a representative payee;	Threat
Offering money, cigarettes, caffeine, etc. in return for a “favor”;	Bribe, attending to staff agenda rather than the client’s choice
Threatening someone with getting thrown out of a residential program;	Threat, misuse of power.
Threatening to “tell the landlord” if a client is choosing not to clean.	Threat

THE USE OF REINFORCERS TO SUPPORT CLIENT CHOICE

Standard 6b

In everyday life we all use reinforcers to assist us in achieving our personal goals and actualizing our choices. For instance, many of us have the goal of wanting to keep our teeth into old age so that we can continue to eat the foods we enjoy. However, in order to achieve that goal most of us conclude that we must choose to go for regular dental check ups and dental work. Many of us find the drills, needles and probes of the dentist to be unpleasant and so we promise ourselves a reward if we go i.e., “If I go to the dentist appointment, I will treat myself to that movie I have been wanting to see”. Giving ourselves rewards not only supports us in achieving our choices and goals, but it is also a way to cope with a fearful situation i.e., going to the dentist is scary but the fear is more manageable if we plan something pleasant afterwards.

In a similar fashion many clients need to learn to reward themselves for going through unpleasant steps in order to achieve their goals and to actualize their choices. Direct service workers can support clients in this learning process through the use of reinforcers. An example would be:

A client has the goal of staying in her own apartment in the community. In order to achieve this goal, she must choose to comply with a court subpoena regarding a past traffic violation. The client is frightened of court and “hates” to go to court. However, failure to appear in court could result in arrest, probation, incarceration and subsequent loss of her independence in the community. In this situation the direct service worker could suggest a coping strategy that would support the clients choice to remain in her own apartment in the community i.e., the worker could say, “I know how difficult going to court is for you. One way to make it a bit more tolerable is to reward yourself. How about if you and I make the arrangements to go for a nice lunch after you’re done in court. Would that help?”

Of course there is a very fine line between using reinforcers to support a client in actualizing their choices and goals, and using rewards to bribe, coerce and threaten a client into doing something. In the above example, bribery, coercion and threat might be conveyed as follows:

“If you go to court I’ll take you out for a special lunch” (this is bribery) or “if you don’t go to court then we are not going to that special lunch we discussed” (this is threat and coercion).

When a Client Can’t Make an Informed Choice

Standard 7

There are situations in which a client is in acute, albeit temporary distress and appears to be genuinely unable to process the information necessary to make a decision. If this is an ongoing condition, then legal counsel should be sought, guardianship considered, etc. However, if a direct service worker notices that an otherwise competent client truly cannot attend to information or understand it, then this should be brought to the attention of the supervisor immediately. Examples of such situations might be :

· That a client is experiencing temporary cognitive impairment due to psychosurgery or ECT;

· A client is experiencing confusion due to toxic effects of a medication;

· A client is experiencing acute distress and is using all their energy to resist commanding voices and has little energy to devote to processing information in order to make choices, etc.

When a Client Won’t Respond to the Choices that are Presented

Standard 8

True choice means that there is a range of options from which to choose. However, we do not always have a wide range of options from which clients can truly make their choice. Due to a lack of resources and the dictates of regulations we must often present clients with situations in which they are asked to respond to one of two options i.e., “you can choose either A or B”. Responding to a forced choice situation and making a choice are not necessarily the same thing.

When clients are asked to respond to a situation by “choosing A or B”, it is not unusual for them to remain mute, to refuse to “choose” or to adamantly insist that they will accept neither A nor B, but instead want C. For example, an elderly woman who moved slowly and was rather frail, lived in a sixth floor apartment program. She was unable to meet standards for evacuation during fire drills. Staff knew that according to regulations the client was “at risk” and had to be moved off of the sixth floor. After thoroughly reviewing the situation staff felt there were two choices for this client. She could move to a first floor apartment, in the same program with the same staff in the same building (Option A). The other option is that she could have gone to a nursing home (Option B). When staff presented the woman with this forced choice situation, the woman adamantly continued to insist that she wanted to live in her current apartment (Option C).

In such situations direct service workers and their supervisors have important decisions to make. They can:

· Assess whether the situation is urgent or can wait so that there is more time to problem solve and discuss the situation with the client and the service system.

· Validate for the client that the situation is difficult and does not represent the client’s agenda.

· Inform the client that if they do not make the choice staff will make the choice for them and then proceed while keeping the client informed at all stages.

· Work as an advocate with the client to refuse options A or B and to creatively take a stand to make option C a reality.