Chaplain Jerry Carter on the balance between autonomy and urgency

A Bronze Bird Cage

Dr. A was passionately concerned for RC. Her concern was evident in the intensity of her conversation. “She is definitely schizophrenic and I fear that she may be on the edge of a crisis. She has cancelled her last two appointments and I feel I need to take some initiative on her behalf. She said you had referred her to Dr. T for counsel. She said she had seen him. Can you find out if she actually saw him? RC needs help, but she does not meet criteria for involuntary admission to a psych hospital. I have got to find a way to get her help!”

My involvement with RC began with a rushed phone call. In a quick statement she said that she had spent the last 4 nights in the chapel and that she had left some gifts there. The click of the phone gave me no opportunity to reply.

RC called back. In a long rambling conversation she affirmed her four night stay in the chapel was to escape the attacks of demons in her home. She wanted to meet with me in person to tell her story. I told her I would like to have our social worker present. (I felt that the social worker could provide qualified assessment of this woman’s mental status.) RC agreed, “As long as she is a Christian! I don’t want no devil woman talking to me!”

RC showed up dressed very neatly. She walked up to the chapel’s golden cross. She said, “Can you see them, they are right there on the cross, I see the demons that are attacking me.” We assured her we could not see anything. Her story was one of loss and estrangement. Her father had died when she was young. Her mother had abandoned her. She had supported herself all the way through high school. During a brief private moment, the social worker assessed that RC was mentally ill but did not appear to be an imminent danger to herself. RC volunteered that she had an appointment to see Dr. A the next morning.

Advocacy for the mental health patient has been one of my concerns. Access to appropriate care is difficult for those with mental health issues. Those in need of voluntary mental health services are frequently frustrated in their attempts to find assistance due to lack of funding or to the long waiting lists for public services. Frustration is also experienced by those who must deal with the patient needing involuntary mental health care. I have often been amazed at the lack of communication and seemingly competing interests of the court system and the mental health system. In both voluntary and involuntary care situations a physician’s assessment is often the gateway to appropriate care.

Knowing that RC would be seeing Dr. A for an initial visit, I felt that the physician needed a heads up with regard to RC’s recent behavior. I asked RC for and received permission to speak with Dr. A. I also felt that referral to Dr. T was appropriate. Part of being a professional chaplain includes knowing when to refer. Experience has taught me that some times the best service I can provide is a referral to someone with a more appropriate skill set.

RC certainly has a right to choose whether to follow up with either her doctor or her counselor. What is the balance between her autonomy and the provider’s sense of urgency for one “on the edge of a crisis”? What if RC had refused my request for permission to speak with Dr. A? Would her obvious mental health issues create a duty to warn the physician? Which has the greatest potential for harm; assertive intervention that may infringe upon her autonomy or drawing a professional boundary that assumes follow up is the individual’s choice? I still wonder what RC was saying when the gifts she left in the chapel were an angel, a rose and a bronze bird cage.

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