July 4 juillet 13:45 – 15:45
Room NCDH–101
Chair: Virginia Aldigé Hiday
, North Carolina State
University
Over the last decade or so, researchers and policy-makers
have become especially interested in determining the extent to which mentally
ill patients who are civilly committed or voluntarily hospitalized perceive
their experience as coercive. This topic has become more salient with the
increased use of outpatient commitment by different states.
The MacArthur Research Network on Mental Health and the Law Coercion
Study has conducted extensive research on this topic. It concluded, inter alia, that the “amount of coercion experienced is strongly
related to a patient’s belief about the justice of the process by
which he or she was admitted.” Policy-makers, clinicians and others are
interested in determining whether treatment outcomes for patients who are
hospitalized or committed as outpatients might be enhanced if steps were taken
to minimize patients’ perceptions of coercion in this process.
During this period there has also been a great deal of interest in the
use of Mental Health Advanced Directives (MHADs) by consumers of mental health
services. This instrument allows a patient to state his treatment preferences in
writing for use at a later time during the hospitalization and treatment
process, should he become incompetent to express those preferences. MHADs may
also reduce patient perceptions of coercion by increasing their “voice” in
the commitment decision and thereby affording them a greater sense that they
have been accorded “procedural” justice. Many observers argue that use of
MHADs can increase patient autonomy and may also enhance treatment outcomes by
providing care that is both more appropriate for the patient and more accepted
by the patient. Both of these factors should increase the probability that the
treatment provided is more effective.
This paper will explore ways in which MHADs may increase patient autonomy
during the commitment process, thereby minimizing patient perceptions of
coercion. It will also explore ways in the use of MHADs can themselves be coercive by limiting patient
decision-making authority, thereby potentially increasing patient perceptions of
coercion. Finally, it will suggest ways in which MHADs can be used so as to
maximize patient perceptions of procedural justice and non-coercion and increase
therapeutic outcomes.
The presentation will focus on legal and practical issues that arise in implementing mental health advance directives (MHADs) in a community mental health system. MHADs are written statements, made by clients, about their treatment preferences, chosen during a time they are able to make these decisions, anticipating a time when they have reduced capacity for communication and decision-making. MHADs will be discussed within the context of, and as a response so, coercive methods in mental health care. We will then focus on findings from the first year of a five-year research grant from the National Institute of Mental Health to examine feasibility and utility of MHADs in two sites in Washington State. Discussion will review issues raised by staff of outpatient, crisis and inpatient services including: perceived and real conflicts with regulations and statutes, circumstances for MHAD ‘activation’ and ‘deactivation’, competency issues in execution and activation, staff involvement in MHAD execution and logistical issues in executing and using MHADs.
The use of seclusion and restraint was analyzed in a 6-month
admission sample of three psychiatric university clinics in Finland. The three
centers are responsible for all psychiatric inpatient treatment of working-aged
patients from their catchment areas. There were 1543 admissions during the study
period. Of the treatment periods, 6.6% included one or more episodes of
seclusion and 3.8% included at least one episode of mechanical restraint. The
mean of the total time spent in seclusion or restraint was 29 hours (SD, 63
hours), median time was 12 hours. In relation to the inmate population,
seclusion or restraint was applied to 81.2/100,000 people per year (95% CI,
72.4-91.1). Involuntary committment and previous commitments, but not ICD-10
diagnosis of the patient, could predict seclusion. Restraint could be explained
only by committment. Seclusion and restraint were predicted by committment,
having experienced previous commitments, and having a diagnosis of substance
use-related disorders (f10-f19). Adding the treating center to the models
revealed a significant facility effect on the use of seclusion and restraint.
The annual rate of use of these coercive measures is high. The fact that the
facility was more powerful a predictor of use of seclusion restrains than
psychiatric diagnosis warrants attention.
Two hundred five inpatients hospitalized at “Hospital de
Clínicas de Porto Alegre”, a large university hospital, were studied. The
sample involved 64 psychiatric patients, 58 surgical patients and 83 clinical
patients who were admitted on a voluntary or involuntary basis. The psychiatric
patients’ willingness to be admitted was determined by their legal status;
surgical or clinical patients’ willingness by the elective or emergency nature of their
hospitalization. The psychiatric patients were younger, of a higher educational
level and achieved higher scores in the SRQ scale than the surgical and clinical
patients. MMSE score did not vary among psychiatric patients, surgical patients
and clinical patients. The Admission Experience Survey: Short Form, an
instrument used in The MacArthur Coercion Study, was given to all patients. The
preliminary results indicate that a) psychiatric patients hospitalized in either
a voluntary or involuntary manner, felt more coerced than the surgical and
clinical patients; b) surgical and clinical patients did not differ from each
other regarding the perception of coercion; and c) logistic regression analysis
indicates that the variables related to the issue of involuntary hospitalization
include the scale of perceived coercion scores, cognitive status and schooling,
all of which produced positive correlation coefficients.
Use of force and coercion in delivering services to people
with general learning disabilities, especially people with challenging behavior,
is widespread. Both the coercive measures and the goals to be obtained vary. Up
until the deinstitutionalisation process of the early 1990’s, which Norway was
forced to adopt through an Act of Parliament, the most coercive measures were
used in relatively closed institutions. A popular
conception was that coercive measures were a necessary component of the
institutional care itself. It was a common view that a more “normalized” way
of living would lead to the termination of most coercive measures. Others
believed that even in a communal setting, some constraint would be necessary. Some empirical works of the mid-90’s showed
that both trained staff and untrained assistants applied a variety of coercive
measures, partly to control challenging behavior and partly to help people
manage their daily activities. Similar measures and reasons were also used in
community-provided home-based services. It appeared that legal instruments were
necessary to restrain
the malpractice of coercive measures. At the same time, such legal instruments
would legitamize some coercive practices. This paper deals with the pro and con
arguments and the legislation for using force and coercive measures when
delivering services to people with general learning disabilities. This debate
closed in Norway in 1996, when Parliament revised The Social Service Act. The
newly written Chapter 6A came into force in 1999 for a three-year trial run. The
chapter regulates the use of coercion when delivering services to mentally
retarded persons with challenging behavior, and establishes specific and
detailed procedural rules to avoid abuse of coercive measures (see paper
delivered by Ole Tom Roed
).
This paper is a follow-up to the paper of Aslak Syse
, and presents the new Chapter 6A of The Norwegian Social Service Act. This
paper deals with both the prerequisites necessary for the use of coercive
measures, and the legal safeguards set forward in order to restrain the use of
such measures. According
to most penal codes, and from a Human Rights’ perspective, a person should be
free to leave his house whenever he likes. Also, it is normally forbidden to
restrain a person’s right to personal freedom within his own home, or to
physically hold him against his will in order to control him or in order to make
him learn more adequate modes of conduct. Adopting such measures in cases of
emergency is, of course, accepted. This Act, however, empowers community service
workers to utilize such measures in a wider range of situations when delivering
services or providing care. Chapter 6A sets standards for when coercive measures
are to be used, and establishes a comprehensive procedural system to legalise
otherwise punishable actions. A panel, The National Board, was appointed to monitor the
practice of the new regulation, and to make suggestions to the Ministry as to
how to regulate this field in the future. Besides giving a presentation of the
specific rules appearing in the Act, the paper will disclose how The National
Board has been operating in the evaluation of a community’s fulfilment of the
material and procedural prerequisites. The main question to be answered is to
what extent this Act has managed to reach the goal of delivering the appropriate
and individual services necessary in the least restrictive environments
possible. An English version of the legislation will be available.
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