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The Mental Health Division of the Public Defender Service of the District of Columbia
takes on clients that are emergency or involuntary patients at psychiatric wards in the district and
want to fight their status. As a social work intern, I assist my supervisor in meeting the clients’
case mangement needs, ensuring the client is efficiently equipped to be discharged into the
community.
Client 3 is a 50-year-old female who is currently at a psychiatric ward in D.C. She has
described herself as having had a “hard life”: she was hit by a car at age nine, has survived sev-
eral rapes, some of which impregnated her, and has a history of illicit drug usage. Client 3 has
never aborted her multiple pregancies from rape, believing that the babies do not deserve to be
punished for an event that is not their fault. As a result, she has ten children, all of whom are ei-
ther in prison, estranged, or do not have their own housing. She is not married. Her mother occa-
sionally visits her, but has not visited in months and has a disconnected phone number. Client 3’s
sister has visited, seemingly as per the request of the mother, but has not returned since being
implored as Client 3’s caretaker. Various children sporadically visit, most with the desire to be
their mother’s caretaker; however, their irregular pattern of visitation and lack of resources prove
they are unreliable and unfit potential caretakers.
Aside from the mental health issue at hand, Client 3 is debilitated by a muscle atrophy
disease. She is in a wheelchair, and is described by the nurses as “total care” – she requires as-
sistance with all hygiene, grooming, and is considered at risk for falls and medication/treatment
refusal. She requires acute fifteen-minute checks, as she has a history of attempting to move in-
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dependently and injuring herself as a result. She cannot transfer independently, as she is inca-
pable of moving her own wheelchair and has minimal dexterity.
Client 3’s official psychiatric diagnosis is major depressive disorder and schizophrenia:
paranoid type. She is considered “hyperreligious”, and has various eccentric beliefs that have led
health professionals to believe she is delusional. Client 3 has a history of not eating for religious
reasons, citing Jesus’ thirty day fast and Deuteronomy 14, occasionally claiming the devil poi-
soned the food, wants her to eat and gain weight, and wants to steal her body and soul, as she
claims God is her body and soul. As she is a diabetic, this often complicates her medication
treatment, as the nurses must withhold insulin when she does not eat. Recently she has been
more compliant in her eating pattern, only skipping one or two meals when she does resist.
Client 3 has had two involuntary psychiatric admissions, in 2009 and 2013 respectively.
Between these admissions, she resided at a nursing home, but was returned to the ward after re-
sisting meals and medication, submitting an array of grievances to the home, and reportedly hav-
ing paranoid delusions. In general, she is resistant to everyday hygiene and self-care. She will not
even minimally assist when nurses are bathing her, brushing her teeth, brushing her hair, etc. She
typically resists showers. Since back at the ward, she has been more compliant with eating, phys-
ical therapy, taking medication/vitamins, and getting her finger stuck (although she still resists
getting her blood drawn). It is important to note that while her compliance has improved, her
compliance is not consistent. It is also important to note that there has never been evidence of
hallucinations while at the psychiatric ward.
Client 3 is socially withdrawn – she will engage when engaged, but does not interact with
the other patients. She says they are all “sick” and “swear too much”. She claims a desire to
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spread God’s word and help them repent, but she has never proselytized. She gets credit for par-
ticipating in groups, but in reality the groups simply happen around her. Client 3 appears lethar-
gic in social situations, but upon inquiry reports being “bored”. She repeatedly shows awareness
of her surroundings, and reports interest in certain gospel/pop music, reading her Bible, and puz-
zles. She always has a pillow on her stomach, which she lays her head upon when she is bored;
she sits straight up and makes eye contact when she wants to engage.
Client 3 reports feelings of sadness because people are not following God. When asked,
she says she will resolve this by spreading the word of God, but never does. Client 3 repeatedly
says she would prefer to be in the kingdom of God. However, she emphatically denies suicidal
ideation and has otherwise never shown any suicidal tendency.
Client 3 has a blatant interest in the Bible and God, but does not seem able to pontificate.
By Fowler’s stages of faith development, she does not appear to be past stage 2: mythical-literal
faith (simplified by M. Scott Peck as the chaotic-antisocial stage). This stage, usually occuring in
middle childhood but sometimes lasting into adulthood, involves self-centeredness, a basic ac-
ceptance of stories provided by a faith community/text, and an extremely literal application. This
often leads to unprincipled living, which can present obstacles. All transitions from this stage, if
they do occur, are dramatic.
Client 3 is currently an involuntary patient at a psychiatric ward because nowhere else
can take her, and she is unwilling to go anywhere other than an apartment by herself, living with
her kids, or in God’s kingdom. Nursing homes will not take her because of her psychiatric needs
and her history at past nursing homes as being a difficult patient. My supervisor therefore turned
to Little Sisters of the Poor, Mother Theresa’s order in the district, as they seem best suited for
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Client 3: they are an all-women environment that adheres better to Client 3’s high religious stan-
dards. Unfortunately, upon meeting her, Little Sisters of the Poor determined they cannot ac-
commodate Client 3’s physical needs. The client has thus far refused a case worker from the De-
partment of Behavioral Health, who can connect her to a housing agency. The client is unable to
live by herself and has no responsible family to speak of. There used to be a psychiatric nursing
home, but it was closed for fiscal reasons. The psychiatric ward is currently keeping her, simply
because there is nowhere else to put her. Her treatment team is working to find a more suitable
living situation, as she does not thrive on the ward. In the mean time, her treatment plan is fo-
cused on increasing social engagement through one conversation with staff per day, three groups
per week for at least ten minutes, and at least three interactions with patients weekly; continue
maintenance of her physical needs; better fill her time with leisure activities; and have bed baths
daily and at least one shower weekly. Upon finding a suitable discharge facility and receiving her
consent, Client 3 will be discharged.
Based on my education thus far from Liberty University’s School of Psychology, I would
not agree with the diagnosis of schizophrenia: paranoid type or Major Depressive Disorder. With
clients like Client 3, the gray area in abnormal psychology is highlighted: after all, her erratic
religious beliefs pose a danger to herself and are not based in reality. But before such heavy di-
agnoses can be made, I feel one must look deeper, and in this case I feel no one examined the
context properly. In an objective evaluation of Client 3’s history and the DSM-V, alongside my
observation of her behavior, I found no evidence of Major Depressive Disorder or schizophrenia:
paranoid type. In fact, I found no evidence for a diagnosis anywhere on the schizophrenia spec-
trum. Her beliefs are stated in passing and are inconsistently acted upon. For these beliefs to be
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delusional, they would have to be consistently acted upon for two months straight. As this is not
the case, she cannot have delusional disorder. She cannot have schizotypal personality disorder,
as she shows no discomfort with interpersonal relationships. Upon meeting her, I found her en-
gaging; she inquired about my hometown and my education, and showed appropriate affect,
laughing and smiling at times. Her lack of a convoy is due to frequent hospitalization, living
among a group of older people she cannot relate to, and perhaps her religious standards and lim-
ited ability to morally reason beyond herself and her own ideas. She shows no evidence of hallu-
cinations, disorganized speech, or catatonic behavior, and is not delusional. She is emotionally
normative, if socially reclusive, and therefore cannot have schizophreniform or schizophrenia. In
order to fit either diagnosis she would need to meet at least two of the criteria, and she meets
none. Therefore, while she has eccentric beliefs and sometimes presents paranoia, it is not
enough to suffice a schizophrenia diagnosis.
Furthermore, while she might present lethargic and catotonic, Client 3 is actually just
bored. She lives with people she cannot relate to, and has a limited range of activities or foods
she will partake in due to her religious standards. Therefore, she is not provided sufficient stimu-
lation or engagement. Otherwise, she is alert, is open when engaged, likes to read her Bible, em-
phatically denies suicide ideation, and enjoys various activities like listening to gospel music and
deciphering puzzles. She reports feelings of sadness, but links them to sadness for the sinners
around her who will not repent. She does not present week-long episodes of depression – her
mood changes like everyone else. Client 3 does not have much to be jovial about – until today,
she did not have her preferred Bible (the Devotional Bible by Max Lucado, which my supervisor
bought for her over the weekend), she has no convoy, she has no opportunity to create a mean-
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ingful convoy, she suffers from a debilitating disease, she is institutionalized, she is often forced
to be dependent due to her limitations, and she is surrounded by swearing “sinners”. Client 3
merely experiences normal sadness, an emotive state anyone might wrestle with in her shoes.
As for Client 3’s resistance to certain foods, medications, social interactions, and hygiene,
I feel they are all spirited attempts to claim control. She cannot walk, cannot move herself, can-
not perform ADL’s independently, is stuck in a broken mental health care system where she has
little say, is estranged from her family, and currently has nowhere to go. There is little she can
control, so I feel she exercises independence and control whenever she can, and does so abra-
sively. With so many restrictions in her life, this does not surprise me, nor does it gravely con-
cern me. I feel she is just trying to fight back, and this sometimes gets her into trouble, which is
the unfortunate reality.
My preferred treatment plan would be to discharge Client 3 to the Little Sisters of the
Poor. She engaged positively with the Sisters and seemed impressed with their environment
(Bible study, gospel music, playing puzzles, no television, no swearing, and no men). Unfortu-
nately, it seems she will not be able to go to the Sisters until she can transfer herself from a bed
to the chair, which has been deemed an unlikely possibility. I would enforce strict, intensive
physical therapy in an attempt to give her the ability to do the minimal amount needed to effec-
tively transfer so that she can be discharged immediately. I would give her a tour of the Sisters’
home, have the Sisters regularly visit her, and even post some of their paraphenilia in her room
so that she can have constant motivation. If this is not a medical possibility, I would discharge
her to a family nursing home that is open-minded to psychiatric patients. I would hopefully dis-
prove the ward’s diagnosis with a second opinion to make this easier. A family nursing home
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would be best for Client 3 as it is like an apartment (which she wants) with only a small number
of people to live with, who can hopefully be matched to her based on personality tests. I would
attempt music therapy, animal-assisted therapy, and perhaps even family therapy. I would pro-
vide as many opportunities as possible for her to exercise control, an advantage found in music
and animal-assisted therapy. She can also exercise control by providing a list of meals she will
eat and give input for her itinerary. I would also move forward with the ward’s aforementioned
treatment plan in its entirety. Finally, I would attempt to construct an incentive system for Client
3 if she partakes in the different aspects of her treatment plan, which might boost subjective well-
being and allow her to exercise control.
