The Dignity of Risk
“Dignity of risk is the idea that self-determination and the right to take reasonable risks are essential for dignity and self esteem and so should not be impeded by excessively-cautious caregivers, concerned about their duty of care.”
[I have assembled parts of some people’s stories for the purpose of narrative below, and fabricated a name. I can feel the tension of not wanting to appropriate someone else’s story and simultaneously wanting to ground this discussion in a visceral example of the truth. I hope that I have done this respectfully.]
I cross the street without looking anymore. Years here will do that to you. It’s late-bitter in New York: February. Hidden 4PM skies oppress. A low-contrast blear of monochromatic pedestrians and anxious traffic obey their ever-metronomes among the impassive towers of stone. The familiar indifference is the lullaby. I could well slumber to the hum if not for the e-bike jump-scares. Seriously guys - you’re going with all black? Too on the nose as a harbinger of end-stage capitalism, no?
I step onto the curb just ahead of certain Grub-Hub death and meet the man. His bare chest and feet are bronzed; his hair’s a wild soot bonfire. He is the light on this block.
“What’s up, Tony?” I ask. He seems to either not recognize me or not care. We’ve known each other for years but I’m often guessing about his intentions, and he mine I’m sure. This is his corner - I’m the visitor.
“Dude, it’s like 20 degrees out here. You want some shoes and a shirt?”
He waves with a shout and and gestures to his mouth. I know the routine. Coffee and an egg sandwich. I oblige, and then chase down the gust-blown brown bag and greasy butcher-paper that skate away after he tosses them aside. I set up on the curb for a while. He doesn’t seem to mind too much. While he engages in a heated dialogue with audiences unseen by me, I chill. I leave some socks, shoes, a hoodie and gloves nearby. He’s not feeling me today. My parting wave is nothing more than a whisper.
An hour later I check in. He’s gone. I see one glove in the drain. I wonder if he’s cold like I am. I wonder whether he’s OK. I wonder what my obligation is to him. I wonder if I can live with not knowing.
The Dilemma
As a “professional helper” within the Mental Health Industrial Complex (MHIC - just making up acronyms at this point) I am often faced with legal, ethical, and moral dilemmas related to the “Overprotect - Neglect Continuum”. That is to say - how do I honor someone’s right to determine the course of his or her or their own life while simultaneously both:
upholding my obligation to a regulating body to not neglect someone enrolled in my program (in my case New York State’s Office of Mental Health), and;
navigating my own fears about their wellbeing?
And even if I am not in a professional helping capacity, bullet 2 still holds for any community member who believes someone is a risk to themselves or others. What are our obligations to “Tony”, the community, and our consciences?
Reasonable people disagree. What is “imminent danger” for one onlooker is “status quo” for another. Is “Tony” a danger to himself because he’s outside without socks, shoes, or a shirt in freezing temperatures? Maybe. There are many unanswered questions. Here are a few:
First - has “Tony” done this before? Is he more resilient than you or I might imagine?
Second - how long is he typically outside? Maybe he heads inside when he’s cold.
Third - even if he is in danger, doesn’t he have a right to make that choice?
The third item is where we get into really fraught territory when we’re talking about the carceral mental health systems. I know plenty of people who drive way too fast. I know several people who free solo rocks at heights that would produce instant death from a slip. I myself used drugs for years in a fashion that smacked of indifference to the value of my life. We are all free to do this. Why? Because we aren’t in the invisible jail of the MHIC.
Those who are in that hidden prison like “Tony” aren’t offered the same dignity of risk. If he does something that makes the Social Worker or therapist or Psychiatrist uncomfortable then he gets sent to the hospital - and locked up for a while. He’ll be “encouraged” to take anti-psychotics or other medications “for his own safety”. If he doesn’t, they can get a swift TOO (Treatment Over Objection) and hold him down and stick the needle in his arm anyway. Why?
One of the hidden Greek soldiers inside the Trojan Horse of a mental health diagnosis like schizophrenia is Anosognosia, as explained here in this bullshit Psychology Today article. Put simply, many believe that those with a diagnosis that include a psychosis component may not have the “insight” to understand that they are “sick”, and thus cannot make “good” or “healthy” or “rational” decisions for themselves. If they only knew, they’d take their medications, right? This egotistical, paternalistic, self-aggrandizing view that mental health professionals take of themselves should revolt you. It’s also not unexpected. Professionalized mental health has long been nothing more than a house of pseudo-scientific cards built in the shifting sands of racist politics and ableist eugenics. But hey, it pays the bills.
The real bugaboo with all of this is that there are rare times where people are not safe in community. This speaks to a bigger failing of society to provide community-based supports for folx so that professionalized “helpers” aren’t the only option. Because so few community-based options exist (like peer-run respite centers, warm-lines, mutual aid groups, etc) - and those that do exist are woefully under-resourced because to fund them would mean defunding the carceral MHIC - we are left with the current system.
The current system has declared that “Tony” doesn’t get to make decisions for himself all of the time. Sometimes he’s too ill to know what’s best for him. Sometimes he should be sent to the hospital. It makes us feel better to know that he’s “safe” and “we did the right thing”. Or at least that we did something. Well, some people think this, anyway. I’m pushing back.
How to proceed?
If I am going to work within the MHIC I have to make some tough choices. Mandated reporting, The Justice Center, my licensing board - I have a lot of oversight. Which of the rules that I have signed on to uphold are hard and fast, and which are flexible? When can I exercise professional judgment? What are the risks to me and - more importantly - to the person I’m serving? Those are the cracks in the system that I want to inhabit.
Evaluating Danger to Self or Others
I almost never have to call 911. 911 makes me feel better, but rarely the person I am calling for. Expressions of suicidality without a specific plan, timeline, and access to means don’t need to be called in. I do need to be with the person. I do need to commit to spending time with them until they feel safe enough for me to disengage. I do have an obligation to connect them with resources of their choosing. But calling 911? Often more dangerous, especially for folks that have been disabled by our society and/or who are Black, or Indigenous, or People of Color, or Trans, or unhoused, or socioeconomically disadvantaged.
And in cases of behaviors that concern me (like weather exposure, walking in traffic, antagonizing passersby, etc.) I can also obviate the need for a 911 call by being present and available. I can express my concerns. I can see if they are interested in navigating to a safer place or making a small change that would improve their safety (like shouting in a vacant lot instead of in a restaurant). I can wave off traffic. I can accompany the person in this moment and help them navigate the potential danger. I can see if the person has a crisis plan that they would like to activate. I can enlist other compassionate supporters. I can call my boss and tell her that I’m going to be late.
Enlisting Support
Speaking of that, I should reach out to my supervisor. I want to use my own supports so that I am not getting too wrapped up in my own emotions around the situation. Am I being neglectful? Am I over-protecting? Are there creative solutions that I haven’t thought of? Is a solution needed at all? When we are talking about potentially denying someone their autonomy (by calling 911) we are talking about becoming explicitly carceral. It’s always implicit, of course, but in this moment my next action might get someone killed in the name of alleviating my own discomfort. Am I really prepared to do that? I encourage folks to get another voice in the room.
Often, Peer staff are either wildly undervalued or misused. The MHIC too often sees Peers as “Junior Clinicians” who get paid less to do harder work. Peers should be paid the same as any worker on a team, and they should be co-leaders on the team in developing an analysis of what crisis support looks like, and in developing crisis intervention strategies. They should also be trusted equally to take the lead during crises, without being abandoned.
Ideally, the loudest voice in the room should be of the person in question. What does “Tony” need right now? Can he vocalize or indicate in another way what would be helpful? What has worked for him before? Is today different? How is it different? Can I put aside my own fears and listen? Can I be present? Can I offer unconditional positive regard? This is professionalism, in my view. Forget the degrees, the licenses, all that garbage. Navigating my own fears and emotions so that I can be available to actively or passively support another person in a time of crisis is the pinnacle of mature social services work.
Education
Much of what I have addressed above starts with an awareness that there’s a problem with the MHIC. The best way for me to heighten my awareness and get energized to make a change is education. I cannot recommend strongly enough IDHA’s current training series, Crossroads of Crisis. People who have survived and continue to navigate the very system that I am a part of are the ones teaching these courses. It’s real “Horse’s mouth” stuff and you can’t find it in a textbook. Don’t think about it too hard. Sign up.
Conclusion
Being part of the MHIC means I am part of the carceral systems that have already caused so much harm to the people I serve. It’s the ultimate gaslighting - the same system that locks people in psych wards one week sends me out to say hello and offer help the next. I need to keep that in the forefront of my mind when I am considering my role in someone’s life. What does support really look like? Am I actually supporting, or am I upholding a system that creates harm? How can I reduce my own negative impact in a service-users life, without neglecting them?
There’s no easy answer. When people tell me what they need, I believe them. I listen and learn. I learn what they define as a crisis, and what they see as needed support. I learn that they want to have the dignity of making their own choices. I learn that they want to have the freedoms that I do - to take chances, to fail, to triumph.
I can cross the street without looking. Why can’t they?