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psych rehab practitioners oppose involuntary outpatient ...

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psych rehab practitioners oppose involuntary outpatient ...

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    1. Nora Barrett Associate Professor & Director of Undergraduate Programs UMDNJ Department of Psychiatric Rehabilitation

    3. 1. Values Conflict Coercive treatment conflicts with the principles & values of psychiatric rehabilitation Key principles/values: Self-Determination Empowerment Maximum consumer involvement, preference, choice Partnership between provider & service recipient

    4. Forced treatment interferes with recovery “Regardless of how it is intended and applied, coercive practice interferes with autonomy and self-determination, which are believed essential to develop the sense of control and personal effectiveness that makes rehabilitation and recovery possible” (Diamond, 1995).

    5. 3. Forced treatment interferes with the therapeutic relationship More difficult to engage and build trust Inability to develop a recovery-oriented partnership Break in the relationship after a violation of the IOC order

    6. 4a. Research Studies on IOC are Inconclusive at Best The most scholarly analyses of scientific evidence for IOC- the Cochrane Collaborative (Kisley et al., 2005), concluded: Only two relevant (randomized/controlled) trials were found NY (Bellevue) and North Carolina studies They were little evidence of efficacy on outcomes such as MH service use, social functioning, mental status, quality of life or satisfaction with care Also no evidence that IOC is more cost-effective New York Study (Bellevue) compared impact of providing an enhanced, better-coordinated package of services with & without the use of a coercive mandate. Found no significant differences in rates of improved outcomes Conclusion: People do better when they are offered better services, not because they are forced to accept them

    7. 4b. Another way to look at the scientific evidence IOC has some effect – but its size is very small One statistical measure used is # needed to treat, i.e. # of persons who must be served to avoid 1 undesirable outcome. It takes: 85 IOC orders to prevent 1 hospitalization 238 IOC orders to prevent 1 arrest By comparison the # needed to treat to prevent 1 hospitalization in an ACT program (an EBP) is 9 Kisely et al., 2005

    8. 5. Violation of Civil Rights “[IOC] fundamentally violates the constitutional right to privacy and due process among individuals in recovery from psychiatric disabilities” (USPRA, 2007). “[IOC] has been historically overused in urban areas and disproportionably applied to people of color” USPRA, 2007). “It is difficult to conceive of another group in society that would be subject to measures that curtail the freedom of 85 people to avoid one admission to hospital or of 238 to avoid one arrest” (Kisely et al., 2005).

    9. 6. IOC is not a Magic Bullet IOC is unlikely to prevent the frightening violent incidents that that typically motivate legislators and advocates to push for such laws In 2009 NYC released a report saying that the individuals involved in the most serious violent incidents were receiving MH care that failed them due to poor coordination, oversight & accountability Man responsible for the VA Tech mass murders had at one time been on an IOC order Unfortunately, tragedies still occur in States that have IOC laws

    10. 7. Mandating use of Medications that have Serious Side Effects Medication is an essential ingredient of recovery for most people living with a severe mental illness However, some people have very good reasons for refusing medications – especially those that produce serious side effects

    11. 8. Increased Stigmaand a Barrier to Treatment People who live with severe mental illnesses already face stigmatizing attitudes from both community members and MH providers Court ordered treatment adds another layer of stigma Concerns about court ordered treatment may prevent some individuals from seeking treatment

    12. Specific Concerns AboutNew NJ Commitment Law Similar standard of “dangerousness” is used for both inpatient and outpatient commitment Can the screeners reliably make the distinction? Family has input into plan of care, but consumer does not Lack of due process (under Kendra’s Law in NY a hearing is required before an IOC order) Lack of sunset provision (to coincide with evaluation period) Lack of a fiscal note to fund the expansion of intensive outpatient treatment

    13. We All Want A Better MH System Access to good community-based MH services for all who want or need them Practitioners trained to use best practices including motivational interviewing and LEAP Frequent use of relapse prevention plans and advance directives Ongoing, intensive case management and outreach teams for all those at risk Families have access to 24/7 crisis intervention provided by caring, responsive & knowledgeable staff

    14. Early Intervention ACT Teams An evidence-based alternative to IOC Or a good strategy for implementing IOC Easy to implement – just expand capacity of our current PACT’s and change admission criteria Consider adding family support specialist to the team Providing intensive outreach services when a person first becomes ill can: Improve long term outcomes and While initially costly, will save NJ money in the long term

    15. Your Ideas On… Developing better crisis intervention and crisis prevention strategies in our MH system Implementing IOC in NJ How exactly do screeners determine who should get hospitalized and who should get IOC? What are the best strategies for providing court ordered services for people at risk for becoming dangerous How do MH providers enforce a court order?

    16. References Amador, X. (2007). I am not sick. I don’t need help, (2nd Edition). Peconic, NY: Vida Press Bazelon Center for Mental Health. State involuntary outpatient commitment Retrieved May 6, 2010 from: http://www.bazelon.org/issues/commitment/moreresources/iocchartintro.html Diamond, R.J. (1995). Coercion in the community: Issues for mature treatment systems. New Directions for Mental Health Services, 66, 3-18. Kisely S, Campbell LA, Preston N. (2005). Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004408. DOI: 10.1002/14651858.CD004408.pub2. www.cochrane.org New York Association of Psychiatric Rehabilitation Services (NYAPRS). Testimony Before the NYS Assembly Codes and Mental Health Committees Public Hearing on Kendra’s Law April 8, 2005. O'Reilly, R. L. (2001). Does involuntary out-patient treatment work? Psychiatric Bulletin, 25(10), 371-374.  Pratt, C.W., Gill, K.J., Barrett, N.M., & Roberts, M.M. (2007). Psychiatric Rehabilitation (2nd Edition). San Diego, CA: Academic Press. Rosenthal, H. (2008). From forcing patients to fixing treatment. Mental Health Weekly June 28, 2008,5-6. USPRA Committee for Persons in Recovery (2007). Position paper in involuntary outpatient commitment. Linthicum, MD: USPRA.

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