July 5 juillet 8:30 – 12:15
(extended session)
Room NCDH–101
Chair: Heather
Stuart,
Queen’s University
In an age of extensive deinstitutionalization in Canada,
patients with severe and persistent mental illness are being discharged earlier
and earlier for reintegration into societies that are ill-prepared to deal with
them, where they suffer from stigmatisation and prejudice. Community
psychiatry’s primary objectives are to establish and promote authentic
autonomy and well-being through continuing support and treatment, crisis
intervention in a timely manner and to facilitate further independence and
purpose through adequate living arrangements, education, occupation and the
recovery of other social roles. However, actualizing these goals poses difficult
challenges due to limited resources and other impediments, such as patients’
refusal to collaborate with their clinicians, sometimes due to a lack of insight
and awareness into their illness. This occasionally results in disastrous
consequences for the individual, family and innocent bystanders, and often
serves to perpetuate stereotyping and other prejudices directed at the mentally
ill.
It seems universally agreed among experts the world over
that there is a crisis in forensic mental health services. However, every expert
has his or her own explanation of the reasons for the perceived crisis, and
equally personal solutions to the problems. This presentation will review the
literature and research to present evidence of the crisis; examine the varied
explanations of many forensic experts for the crisis and present a plan for a
research study to systematically document the trends in forensic mental health
services and some of the possible antecedents/correlates of those trends.
This presentation examines the research and theory offered for Programs of Assertive Community Treatment (PACT), the model that is supported by Institutional Psychiatry as the most well validated and best model of intervention for the Severely Mentally Ill.
This program has been researched for over 25 years, and the extensive literature on this model claims to have established its efficacy on both the systems and patient level. My critical review disputes these claims. I reviewed the empirical evidence of the randomized controlled trials of PACT as well conducted a conceptual analysis of the theoretical framework and a situational analysis of the problem situation of the PACT inventors.
I found that no superior efficacy could be attributed to PACT methodology when compared to no treatment or standard treatment control groups. Any statistically significant impact putatively favoring PACT is a tautological outcome based on administrative rules differentially applied to PACT and CONTROL groups, or are misattributions of worker activity as client outcome, or are based only on data supporting various outcomes and the ignoring or minimizing of negative results which contradict such claims, or are based on manipulation of data to indicate significance for variables which are not supported by the data (ie, collapsing various outcome variables some of which are statistically significant, but are tautological, like number of hospital stays, and some which are not statistically significant but empirically important, like less homelessness or less time spent incarcerated, and suggesting that the significance found (derived from the tautological components) indicates treatment effectiveness for the non tautological components).
Finally, the conceptual analysis of this model demonstrates that this model is coercive and may lead to harm (ie, excessive suicide among its treatment population).
In an age of increased concerns about limited health care
resources and heightened emphasis on individual rights and freedoms, there is
sometimes a tendency in psychiatric practice to hold patients responsible for
their therapeutic stagnation or deterioration. When a patient’s condition
appears to be at a standstill or worsening (albeit not dangerously), it is
sometimes argued that the patient may be ‘resistant’ or not ‘treatment
ready’. Therapy should therefore be discontinued and the patient discharged
(perhaps until such time when he or she is more ‘ready’ for therapy, which
sometimes means waiting for lengthy periods of time for re-entry into a program,
decline in the patient’s condition and increased distress experienced by
caring families). Patient accountability for ‘relapse’ or lack of progress,
for example, assumes that the patient has volitional governance over his or her
illness, able to control therapeutic gains at the rate that clinicians desire.
The primary problem is created when responsibility is shifted onto the shoulders
of an already deeply troubled patient, who legitimizes the clinician’s perception by reverting to
unhealthy coping skills and other negative behaviors. In this paper, the authors
critically explore this phenomenon, critique key concepts, and provide
guidelines to enhance clinical outcomes using ethically justifiable means.
Southwestern Ontario (SWO), a geographical region with 10
counties, has a population of 1.4 million. This region is experiencing
fundamental changes in the structure of mental health care provision. A transfer
of governance from two provincial psychiatric hospitals to one tertiary care
facility in London is planned for 2001, along with reduction and re-distribution
of tertiary acute care beds in London, relocation of beds to other communities
and enhanced community-based services. Reform is focussed on those with severe
mental illness (SMI) as defined in policy papers. To study the effect of de-institutionalization
on acute care hospitals, a retrospective observational design was used. Hospital
discharge abstract data from three tertiary acute care hospitals in London in
1997/98 were analyzed and will be
updated annually. In the baseline year, 1841 discharges with mental
illness as the most responsible diagnosis represented 1431 persons admitted
once. Multiple readmissions occurred with 1.3% admitted more than six times; 90%
of first admissions had a length of stay (LOS) <30 days, 7.6% between 31 and
60 days, and 2.4% >61 days. Affective psychoses represented the majority of
first admissions with LOS <30days. Significant differences in diagnoses, age,
gender, method of admission, LOS, readmission and transfers among the three
hospitals revealed variation in practice patterns. Indeed 29.7% of admissions
did not meet SMI criteria. The majority of admissions (72%) were through
Emergency: the issue of planned admission and monitored care is of concern.
Predictors of LOS and readmission.were examined. Future data will assess the
impact of mental health reform in SWO.
In late 1992, new mental health legislation came into effect
in New Zealand, introducing community-based compulsory assessment and treatment
orders as an alternative to hospital involuntary treatment. Use of the various
provisions of this Act
is reviewed for the eight years since its introduction. The effects of the legislation on
clinical practice and on delivery of mental health services will also be
reviewed.
Southwestern Ontario serves as a ‘natural laboratory’ for the study of deinstitutionalization because of the downsizing of two provincial psychiatric hospitals in the region. We provide a history of restructuring efforts, and report preliminary findings from a multidisciplinary research project on this topic that incorporates both quantitative and qualitative methods.
Among our findings: The population with ‘severe mental illnesses’ (SMI) is highly heterogeneous–a fact not reflected in official definitions used for purposes of health planning. Because of the inadequacy of existing tools, a comprehensive, client-centered model had to be developed for purposes of outcome assessment. Although comparisons must be made cautiously, Canada apparently spends far less than the United States in caring for patients with schizophrenia. Data on the indirect costs of mental illness are extremely difficult to obtain, as are cost data from other areas of service provision.
Trans-institutionalization–the provision of ‘care’ within another sector without the transfer of funds–is an especially important phenomenon. (1) We find that the lack of systematic assessment of people in provincial jails leads to substantial under-reporting of the prevalence of SMI among inmates. (2) Tracking interactions between police and people with SMI will also allow examination of trans-institutionalization. (3) Substantial changes are evident in patterns of acute care hospital admission, as are substantial differences among hospitals in patterns of psychiatric treatment.
Much conventional wisdom about deinstitutionalization and ‘care in the community’ is probably wrong, and certainly is not evidence-based. The model we have developed should be widely used in health system planning in other jurisdictions as a way of addressing this problem. We also need to consider the proposition that cost savings from deinstitutionalization may be achieved only at the expense of service quality in the community, thus requiring normative choices about society’s level of obligation toward people with SMI.
In 1992, a National Mental Health Policy was released in Australia aimed at improving the quality of life of people with mental illness by returning long term residents of psychiatric institutions to community life. This process involves the downsizing of state run public hospitals and the mainstreaming of mental health services into the general health care system. The deinstitutionalisation movement was given a significant boost with much optimism, yet numerous problems associated with the change have since been identified. One in particular, is the lack of adequate community-based accommodation and commensurate mental health services for people who are disabled by their mental illness. A substantial number of people are found to be living in boarding houses and hostels.
Boarding houses have been identified by various State and National reports and discussion papers as posing the greatest risk to the safety, well-being and protection of human rights of vulnerable residents such as people disabled with mental illness. As such, most of the discussion will focus on the establishment of the Hostel Industry Development Unit in Queensland and proposed legislation that will directly impact on residential services such as boarding houses.
In view of the likelihood of a continued increase in the demand for boarding house and hostel type accommodation, and the growth of privately run rather than public funded facilities in Australia, coupled with the globalisation trend, urgent consideration must be given to this issues. Queensland Governments have consistently raised the need for legislation to regulate residential services.
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