A gag pamphlet created by a co-worker.

Our unit is given the authority and the responsibility to place clients all throughout the system of care. We essentially control every "BED" everywhere, save the "bed" on the sidewalk or in a park that homeless folks utilize, and the beds people sleep in in their owned or rented homes. Everything else is controlled; from every Hospital bed, to Jail bed, to every shelter bed, to skilled nursing bed, to board and care bed, to independent living bed, to residential treatment bed, to locked facility beds, to half-way house beds...you name it, we control it...we're talking thousands of beds here.

The most challenging and at times frustrating aspect of our job is when we are asked, or rather compelled, to transition our most challenging patients (psychiatrically and medically) out of higher, more expensive levels of care and into less expensive levels of care; for example, from a locked psychiatric ward and into the community. From a philosophical perspective, this makes moral, ethical, fiscal, and clinical sense.

1. A hospital bed costs 1500 dollars a day. A bed in the community costs anywhere from 25 to 600 dollars a day.

2. Locked psychiatric units are designed for folks who are psychiatrically acute, meaning a very recent episode of "danger to self or others, or grave disability". If a patient has compensated from their psychiatric episode and no longer meet legal criteria, it is completely unethical to hold them against there will in a locked setting.

3. Maintaining a patient, psychiatrically compensated and no longer needing a locked setting, in a volatile setting exposes that patient to a high risk of abuse and violence. It is flat-out WRONG to maintain a client in a potentially dangerous environment when they no longer need to (prep. sorry).

4. Crazy environments are crazy-making. When clients have compensated well enough to manage at a lower level of care, continuing to maintain clients in clinically inappropriate settings negatively impact the prognosis of their psychiatric recovery.

With that said, the challenge remains: "Where the Hell do we place some of these clients!?" Patient advocates, Ombudsman's, State Licensing, Doctors, Social Workers, Families, and Psychiatrist expect our system to have an answer for EVERY client that we come across. The expectations are at times both completely unrealistic, bordering on Utopian, and utterly self-righteous.

Often times our teams find ourselves in political struggles and philosophical debates between the system (us) and client advocates regarding where, when, how, and what should be done with the clients we serve. And within this cauldron of frustration and debate, workers within can alleviate a bit of tension by inserting a bit of humor.

Here is a fake pamphlet one of my colleagues created of a fictitious home. I don't think you'll find it at all funny, but to folks in Bed Control, it is a complete riot. I made the mistake of passing this around to a bunch of therapists and social workers I sometimes eat lunch with. Some got the humor while others thought it was over the line. I stood my ground, especially re. the fake email "We'llslap'em4u@RiaootnManor.com". I responded with..."some of our clients need to be slapped"....GASP!

I continued..."If one person CONS another person for ten thousand dollars, that person can be arrested, convicted, and thrown in prison. On the other hand, when you have ONE manipulative malingerer (with a contrived factitious disorder and deliberately exaggerated psychiatric symptoms) conning our system of precious resources and expensive housing to the tune of 1.75 million dollars over 24 months, what do we do?!?...NOTHING, no outrage let alone an attempt to CHALLENGE or even QUESTION that client's claims of disability. Instead, what we do is continue to bash that square peg into that round hole...brilliant."...no answer. I deftly tossed the report re. the clients history of cost to the system onto the center of the table (names and identifying info. removed according to HIPAA regulations of course).

I mentioned that it was AS IMPORTANT to serve our clients as it was to delegate our efforts to those clients MOST IN NEED OF OUR SERVICES AND RESOURCES. We simply cannot serve everyone with the same intensity of service; it is neither good for the client or the service worker. We MUST make difficult clinical judgements regarding who we serve as well as the degree to which we invest our resources toward their care. One social worker (whom I like and respect) said, in jest, "You sound burnt out". I responded that I was in fact the opposite! That I was more excited about the work than ever! I clarified that I was in NO WAY frustrated with our clients,...rather it was the other way around!...I was frustrated with folks who serve our clients.

Enough of that, here's the pics.




BTW, R.I.A.O.O.T.N. stands for "Running In And Out Of Traffic Naked".