Interview with Hillary Paffenroth, ASW on Psychiatric Social Work

About Hillary Paffenroth, ASW: Ms. Paffenroth has been a psychiatric social worker for Comprehensive Crisis Services, an organization within the City and County of San Francisco’s Department of Public Health (DPH), since 2010. She began her social work career at a residential treatment facility for boys who suffered severe abuse or neglect, and who needed mental, emotional, and behavioral support. At this facility, she progressed from child care worker to Therapeutic Behavioral Services (TBS) clinician to Day Treatment Clinician.

Ms. Paffenroth then transitioned to a position as an on-call clinician for Child Crisis Services, a part of Comprehensive Child Crisis Services. In 2011 she was hired by Asian American Recovery Services, Inc. as a full-time psychiatric social worker for Comprehensive Child Crisis Services. After two years in this role Ms. Paffenroth progressed to her current position as a psychiatric social worker for the City and County of San Francisco DPH. She completed her MSW at Cal State East Bay in Hayward, CA in 2009. Hillary Paffenroth was compensated to participate in this interview.

[] Can you give an overview of your core responsibilities as a Psychiatric Social Worker at Comprehensive Crisis Services? What types of clients do you work with, and what kinds of challenges do they face? How do you support them?

[Hillary Paffenroth, ASW] I started my time at Comprehensive Crisis Services with the Child Crisis team and now work on the Mobile Crisis team. The Child Crisis team works with children, and the Mobile Crisis team works with adults. Both teams focus on psychiatric crisis intervention, most often in the form of a formal evaluation to determine if the individual meets the criteria for involuntary psychiatric hospitalization. In California this is known as a 5150 evaluation. You must be authorized to place someone on a 5150 hold, and most 5150s are done by police. Needless to say, we often work very closely with police, paramedics and other medical professionals in the course of our work.

If an individual does meet the criteria for involuntary hospitalization a member of my team places them on a 5150 hold and they are (most often) taken to a psychiatric emergency room for further observation and/or treatment. The reasons that an individual would be placed on a hold are that they are currently: a danger to self, a danger to others, or gravely disabled. The first two categories are fairly straightforward, if someone is suicidal or homicidal, or if their actions are placing themselves or others at significant risk of danger, they would meet criteria. The third category, gravely disabled, means that an individual cannot take care of their most basic needs such as eating, bathing, having a place to live, attending to a serious medical condition, etc. A person is not gravely disabled just because they are homeless. However, if a person is homeless and cannot make use of shelters, soup kitchens, maintain a basic level of self-care and are at risk of serious harm or death, they could be placed on a hold.

Additionally, if someone is experiencing psychotic symptoms that are putting them at risk (i.e. not eating because they believe food is poison, or unable to make reality-based judgments) they may be placed on a hold. Youth are seen in a variety of settings including hospital emergency rooms, schools, group homes, and the Child Crisis office. Adults are seen anywhere, hence the name “Mobile Crisis.” We serve a majority of the severely and persistently mentally ill population in the city. In addition to psychiatric evaluations we provide resource information and linkage to resources.

A 5150 evaluation is so named because that is the welfare and institutions code that legally allows a person to be placed on an involuntary hold. Placing someone on a hold is not to be taken lightly as it can impact people’s lives very seriously. We need to make sure that we are adhering to the law and not placing people on holds without establishing legal criteria. We often work closely with the police psychiatric liaison, an SFPD officer with a background in psychology, who is the designated officer to handle cases that include known mental health issues.

We generally do not provide therapy or counseling. We are designed as a short-term crisis intervention service and do our best to link people to services for on-going treatment. On the child team this is done via formal case management in which we link the child to therapy and psychiatric services as soon as possible. They may be seen for short-term therapy and/or medication support pending linkage to other providers if necessary. On the adult team, linkage is done primarily via direct referral to the client or client’s support system–that is, informing them of resources as well as how and where to access them. The Child Crisis Team has a psychiatric social worker in the role of Hospital Discharge Planner who works with parents, families and providers to coordinate services for the child upon their discharge from the hospital.

[] For students who are just learning about psychiatric social work, can you give an overview of your team and how psychiatric social workers collaborate with other medical professionals to provide psychiatric care? For example, do you work with psychiatrists, psychiatric nurse practitioners, and clinical psychologists?

[Hillary Paffenroth, ASW] Our team is made up of psychiatric social workers, MFTs, psychologists, psychiatrists, nurses and health workers. Our calls primarily come from concerned family members, police officers, teachers, mental health providers, primary care physicians, ER physicians, and concerned people in the community. We are whom they call when they don’t know who else to call. We act as consultants much of the time, advising people as they try to navigate getting help for a loved one, patient or client.

We interact with other professionals in a very unique way. Sometimes when going on a call in the field we know there will be safety concerns. In these instances we call for police assistance prior to contacting the individual we are going to assess. Other times the police call us because they want to help an individual who may be experiencing issues with their mental health but the police do not feel they can be placed on a 5150. We also often collaborate with treating medical doctors, psychiatrists, therapists and other providers when gathering information prior to an assessment as well as when making recommendations for follow-ups or linkages after an assessment. One of the things I love about my job is that I get to work with a wide range of people in many different settings. I never know where I’ll be going or what to expect when I start my work day, and it never gets boring.

[] Why did you decide to work in psychiatric social work? What have been some of the highlights of your experiences at AARS and Comprehensive Crisis Services?

[Hillary Paffenroth, ASW] I decided to become a psychiatric social worker partly because it is a way to combine my interest in the law with my interest in mental health and helping people.

I graduated with my bachelors degree in Criminal Justice from Long Beach State and really did not know what I wanted to do. I was inspired to get my MSW after working at a level 12 and 14 residential treatment facility for boys age 6-18. I worked as a child care worker (aka counselor) and realized that I was interested in the work that the individual therapists were doing with the boys. I wanted to do that. So, I went back to school. Little did I know at the time that the end result would be a career which, in many ways, merges Criminal Justice and Social Work.

I knew I was interested in the field of criminal justice, but was somewhat disheartened after completing my undergrad degree because I saw the field as being focused on punishment and consequences and, for the most part, overlooked prevention and rehabilitation. I saw that I would rather work in a field in which I felt I could better directly help those in need. Perhaps I could even help people in a way that could result in them not ending up incarcerated in the first place! (I would like to add that law enforcement officers do often help people in very meaningful ways, however there are also many other aspects of being a police officer that did not appeal to me).

I’m very happy where I ended up professionally, although it is not quite where I initially intended to be. After my first year of grad school and completing an employer-based internship as a TBS worker I had the opportunity to intern on the Berkeley Mobile Crisis Team. I knew without a doubt that this is what I wanted to do. But I was not in the right academic concentration. I was told I could not do it as a student focused on Child Youth and Families. So, after much thought, I advocated to change my concentration to Community Mental Health, which would allow me to do the internship I really wanted. I was lucky enough to be offered the position and it was amazing! I learned and grew so much as an individual and a professional. I became confident in abilities I never knew I had. I also gained the experience that would lead me to my current position as a psychiatric social worker. That internship changed the trajectory of my career and I’m so happy it did.

One area I would like to highlight about this work is the way we help the people who are not the direct client. For example, family members, friends and even experienced clinicians call us when they have encountered a serious crisis or when they do not know what to do and need help. It is extremely rewarding to offer these people help in their time of need. Family, friends and providers are often profusely thankful and tell us that they do not know what they would have done without our help. Through this kind of feedback it is clear that the impact of our service goes beyond just helping the client get to the hospital. We can start someone on the road to help and recovery in a way that most other providers cannot. That makes my job pretty special.

[] What are the most challenging aspects of your job? How do you recommend students who wish to enter psychiatric social work prepare themselves to face these challenges?

[Hillary Paffenroth, ASW] One of the most challenging aspects of my job is the potential danger. When going out into the community to do evaluations I do not know what to expect. I try to gather as much collateral information as possible before going, however you still do not know what you are walking into much of the time. It is very important to use your judgment to assess safety risks or concerns and try to take proactive measures (such as going in conjunction with the police). The best was to address the safety challenges is to be very aware. This starts by asking the referring party if the individual has a history of violence or has made any threats of violence, gathering as much about the individuals history as possible. Once on scene, continue to be aware of your surroundings, do not enter someone’s home if you feel threatened or unsafe. We always go out in teams of two and we always make safety a priority.

[] For MSW students who are interested in becoming psychiatric social workers, what advice can you give them about optimally preparing for this field while pursuing their degree? Do you have any additional advice you would like to give current and prospective students who are interested in clinical social work and/or psychiatric social work?

[Hillary Paffenroth, ASW] If your MSW program has more than one area of concentration, make sure you choose the right* one. As I stated earlier, I was initially enrolled in the Child Youth and Families concentration, however this limited my internship options and ultimately would have limited my career options if I had stayed within that concentration. Changing to Community Mental Health felt like a big step and was somewhat scary at the time. In hindsight it was a very wise choice. So my advice is to be flexible and don’t limit your possibilities just because you have a certain mindset going in. Finding an internship in an area that interests you as far as a long-term career is ideal. Getting that experience will help tremendously when seeking employment. I would also encourage people to take per diem or part-time work when just starting out in the field as it can turn into something full-time or permanent when a position opens up at that agency. I juggled several part time positions prior to being employed full time with Comprehensive Crisis Services. It was difficult but ultimately paid off.

Also, if you find you want to change the direction of your career at any time, do it! Volunteer, work awful hours, get those things on your resume that are directly relevant to what you want to do. It will pay off eventually.

Additionally, if your program offers elective classes on clinical diagnosis and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), take as many as you can! This is an area in which I wish I had more formal classroom education. I have become a strong clinician in this area due to the nature of my internships and jobs, however feel this was lacking in my overall academic work. If you are like me and generally disappointed in the level of instruction taught to social work students in the area of diagnosis, advocate for yourself at your internships, see the professor who teaches the DSM class at her office hours, choose it as a research paper topic if possible. Be proactive in learning to diagnose, because you will be doing it all the time.

*Disclaimer: if you don’t pick the “right” concentration because you don’t know what that means for you yet, don’t worry. It’ll work out! Just keep moving forward and you’ll find what “right” is for you.

Thank you Ms. Paffenroth for your time and insights into psychiatric social work.

Last updated: April 2020