Involuntary Treatment Meeting Summary

Meeting Objective Three:
Generate Recommedations for CMHS
Regarding Knowledge Dissemination Training,
Services Demonstration, and Research

In discussing involuntary mental health interventions and coercive practices, the value of freedom and choice in services, the negative consequences of coercion, the ubiquitous stereotype of the violent mental patient, and the perceptions of coercion by consumers need to be considered. These issues infuse the context of the discussion, but may not be apparent in the more narrowly framed research and policy questions addressed by mental health professionals.

- Jean Campbell, Ph.D., in "Involuntary Mental Health Interventions and Coercive Practices in Changing Mental Health Care Delivery Systems: The Consumer Perspective," a paper prepared for the 12/97 CMHS meeting

The third and final objective of the meeting was to generate recommendations for activities that CMHS might pursue regarding knowledge dissemination, training, research, and policy. The lack of accurate, uniform data about the frequency, duration, and type of involuntary interventions occurring nationwide was the primary and most often mentioned deficiency in current knowledge. The strong desire for more information about the effects of involuntary interventions on individuals with mental illness, their friends and families, practitioners, and society as a whole, was evidenced by the long fist of proposed research questions. Recommendations in each of these categories are listed below.

Knowledge Dissemination

CMHS is uniquely positioned to collect and widely disseminate information about current practices that are effective in reducing coercive practices. The following specific knowledge dissemination tasks were proposed.

Document best practices in crisis prevention and alternatives to voluntary hospitalization or involuntary commitment. Include consumer-directed service alternatives, such as the Crisis Hostel demonstration project developed by Jeanne Dumont.
Develop clearly-written and accessible resource materials on each of the major psychotropic medications including intended effects, side effects, and precautions, but without all of the information in the Physician's Desk Reference (PDR).
Develop a state-by-state compendium of laws on confidentiality, professional liability for treating or failing to treat, and related case law.
Develop a state-by-state compendium on state patients' rights laws.
Develop a state-by-state compendium of informed consent protocols. Broadly disseminate the Massachusetts model informed consent policy.
Disseminate the forthcoming state-by-state compendium of laws on advance directives by the National Association of Protection and Advocacy Services (NAPAS). Compile and disseminate an analysis of case law to date on advance directives and durable power of attorney for health care regarding mental health treatment.
Develop video-based training materials that documents the experience of people who have been involuntarily committed.
Through the CMHS National Mental Health Information Center, establish an Internet discussion group on coercion and involuntary interventions. Periodically summarize and publish the content.
Update the study by the National Association of State Mental Health Program Directors (NASMHPD) on state mental health agency commitment to and actions in the area of consumer-directed services (entitled "Putting Their Money Where Their Mouths Are").
Summarize and disseminate the information already available on the NASMHPD Research Institute's State Mental Health Agency Profiling System regarding coercive practices by state mental health agencies (e.g., frequency of involuntary commitment, which states use outpatient commitment, etc.).
Add explicit language to CMHS grant agreements regarding the role of grantees in protecting the civil rights of patients in public or private institutions.

Training

Several recommendations were articulated regarding the preparation of mental health practitioners and others who treat consumers during crises.

Encourage the involvement of consumers and family members in professional training (e.g., training of new hires on inpatient units, training of police, and psychiatric residency training). Include material on the safety and health effects of coercion, how to avoid the need for coercion, and the principles of rehabilitation and recovery.
Encourage residency programs to select psychiatric residency training sites in the community and not only in hospitals.
Develop a peer training program to prepare individuals to create advance directives and durable powers of attorney for mental health care.
Advocate for a change in JCAHO standards to require the training of care providers in mediation techniques.
Encourage medical schools to change the culture of mental health treatment and reduce the use of coercive practices. Develop more effective techniques for training practitioners to be respectful, show concern, listen fully, and treat consumers and family members with dignity.
Encourage medical schools to require trainees to undergo short-term experiences of psychiatric treatment (e.g., seclusion, restraints, or psychotropic medications).

Services Demonstration

The discussion included calls for a variety of demonstration projects regarding: 1) services that might prevent the escalation of situations to the point that crisis intervention is needed; 2) features of crisis services that minimize coercion; 3) the efficacy of various modes of crisis intervention; and 4) the outcomes of large-scale initiatives to reduce involuntary interventions and coercive practices. The group recommended the dissemination of information about service models found to be effective in achieving these goals.

Fund more small demonstration grants (e.g., on alternative approaches to crisis prevention and intervention) rather than long-term research so that existing knowledge is documented and disseminated more quickly.
Assist in the development and evaluation of programs designed to help individuals create advance directives and durable powers of attorney for mental health care as well as methods for rapidly alerting practitioners to their existence. Study the effectiveness of mediation, advance directives, and durable power of attorney for health care in reducing the need for coercion. Disseminate the results of the two-tiered protection & advocacy system in Maryland that compels mediation by patients, staff, administrators, and advocates regarding involuntary interventions.
Examine the effectiveness, including cost-effectiveness, of consumer-directed crisis alternatives.
Demonstrate methods for increasing the efficacy of informed consent procedures (that is, providing clear, accurate and complete information, promoting the competency of the individual to give consent, and prohibiting coercion to induce consent).
Study the effectiveness of current state initiatives to reduce involuntary interventions. Data available from the NASMHPD Research Institute's State Mental Health Profiling System indicates that one-half of the state mental health agencies have undertaken initiatives to reduce seclusion and restraints, one-third to reduce forced medication, and one-third to reduce involuntary commitment. However, these data are self-reported and it appears that no studies have yet been done on the effectiveness of the initiatives in actually reducing the frequency of involuntary interventions.
Study and report how individual psychiatric inpatient units have been able to achieve dramatic reductions in the use of seclusion and restraints by setting a goal of doing so.

Services Demonstration

Fund more small demonstration grants (e.g., on alternative approaches to crisis prevention and intervention) rather than long-term research so that existing knowledge is documented and disseminated more quickly.
Assist in the development and evaluation of programs designed to help individuals create advance directives and durable powers of attorney for mental health care as well as methods for rapidly alerting practitioners to their existence. Study the effectiveness of mediation, advance directives, and durable power of attorney for health care in reducing the need for coercion. Disseminate the results of the two-tiered protection & advocacy system in Maryland that compels mediation by patients, staff, administrators, and advocates regarding involuntary interventions.
Examine the effectiveness, including cost-effectiveness, of consumer-directed crisis alternatives.
Demonstrate methods for increasing the efficacy of informed consent procedures (that is, providing clear, accurate and complete information, promoting the competency of the individual to give consent, and prohibiting coercion to induce consent).
Study the effectiveness of current state initiatives to reduce involuntary interventions. Data available from the NASMHPD Research Institute's State Mental Health Profiling System indicates that one-half of the state mental health agencies have undertaken initiatives to reduce seclusion and restraints, one-third to reduce forced medication, and one-third to reduce involuntary commitment. However, these data are self-reported and it appears that no studies have yet been done on the effectiveness of the initiatives in actually reducing the frequency of involuntary interventions.
Study and report how individual psychiatric inpatient units have been able to achieve dramatic reductions in the use of seclusion and restraints by setting a goal of doing so.

Research

The following list of issues and considerations related to research emerged from the discussions.

Arrange for consumer direction in all phases of the research (including the framing of research questions, research design, informed consent, monitoring, data analysis, reporting, and dissemination).
Design research in a way that questions the whole principle of involuntary intervention rather than assuming it will exist.
Study the harmful effects of coercion, including iatrogenic effects such as learned helplessness, re-traumatization, and the loss of freedom and liberty.
Question how free participants really feel to comment on their satisfaction with services or preferences if they are being involuntarily held at the time of a research interview.
Keep in mind that research on victims of abuse has found that people tend to under-report such experiences, perhaps because they wish to maintain a sense of autonomy as long as possible. This implies that, similarly, consumers may under-report perceived coercion or otherwise be slow to self-identify as having been coerced.
Clearly define the criteria for assessing the level of "need" for inpatient care and identify the extent to which this is a subjective judgment which could vary from practitioner to practitioner or vary depending on the range of alternative supports available locally.
Distinguish in research between situations in which the individual is persuaded/threatened vs. physically held on an inpatient unit or forced to submit to treatment.
Frame research as investigating rights issues, not just treatment issues. For example, consider the extent to which involuntary interventions are used for custody or social control purposes.

Specific Research Questions

While research findings were presented and discussed at the meeting, there are still many unanswered questions regarding involuntary interventions and coercive practices. The group generated a large number of proposed research questions.

Why do individuals refuse treatment?
How frequently are coercive practices occurring presently across various settings (including state hospitals)?
To what extent are current policies, procedures, and statutes followed in letter and spirit?
What is the relationship between enhanced procedural justice and perceived coercion?
What percentage of current expenditures on mental health care is for involuntary interventions?
What life or treatment events precede and surround involuntary interventions? Which services, if available, could have prevented the need for hospitalization?
Which services or practices effectively prevent the need for involuntary intervention (e.g., types and effectiveness of diversion programs)?
Does the pro-active development of advance directives and durable power of attorney for health care reduce the need for and frequency of coercion?
What is the frequency and efficacy of prescriptive vs. proscriptive advance directives for mental health care presently in use? What are the characteristics of advance directives that "hold up" when needed and actually result in an individual receiving the care he/she prefers?
Can the training of consumers, family members, and practitioners in mediation skills reduce the frequency of coercive practices?
Will the growing application of managed care in the public and private sectors increase or decrease coercive practices?
Is there a relationship between the implementation of managed care principles in a mental health system and an increased reliance on involuntary commitment?
Is there a relationship between the implementation of managed care principles in a mental health system and an increase in the number of people with serious mental illness in jails or shelters?
Can managed care organizations shift financial incentives so as to promote voluntary treatment and discourage involuntary interventions?
What is the cost-benefit ratio in the trend toward requiring clinicians to frame clinical notes in terms of performance outcomes? Are we actually providing better care, or is too much time being taken away from direct service for paperwork to justify the means?
What is the relationship between the use of coercive practices and client satisfaction?
How does use of coercion and involuntary intervention vary by race or gender?
What are the attitudes and behaviors of practitioners with respect to involuntary interventions? Do derogatory or otherwise prejudicial attitudes toward people with mental illness make it more likely that practitioners will engage in coercive practices?
Is there a relationship between derogatory or otherwise prejudicial attitudes toward people with mental illness among the general public and their support for involuntary interventions? What are the characteristics of an anti-stigma campaign that actually reduces these prejudicial attitudes?
What are the short-term and long-term effects on family members, friends, and practitioners of participating in coercive practices?
What happens to people who are evaluated for involuntary commitment but are not admitted? For example,
- which services do they receive?
- what is the course of their illness?
- how is their quality of life affected?
- do they end up in jails or shelters where they are subjected to coercive practices?
What happens to people who want to be hospitalized but cannot gain access or otherwise are not admitted? For example,
- are they more or less likely to be harmed?
- are they more or less likely to harm others?
- are they soon committed involuntarily by another practitioner?
- what is the course of their illness?
What is the relationship between the use of coercion and the willingness to seek or accept treatment voluntarily in the future?
Is there a relationship between coercion in the name of treatment and later violence done by the individual who is coerced?
What are the long-term outcomes for individuals who are given treatment choices other than medication?

Policy

One of the purposes of the meeting was to solicit new ideas about changes in policy that would help to reduce the need for involuntary interventions and coercive practices. The following are some of the recommendations put forth during the two-day meeting.

Since there is a tremendous need for uniform data on the frequency and type of involuntary interventions occurring at present, CMHS should consider requiring uniform data from the states as part of the annual reports from state mental health planning and evaluation councils.
It was suggested that CMHS should establish a policy barring the use of any of its funds for research, service, or service demonstration activities involving involuntary interventions.
It was suggested that, through NASMHPD all states could be encouraged to adopt the Massachusetts guidelines on seclusion and restraint for all patients (including public and private treatment settings). CMHS could provide funding for training, materials, etc., with consumers/survivors playing a significant role in any training effort.
One proposal to end involuntary interventions was to make individuals initiating involuntary commitment financially liable for its cost. A method by which CMHS could pursue this end would be to work with the National Association of Counties (NACO), NAPAS, and the Bazelon Center for Mental Health Law to identify and promote a test case regarding financial liability for unwanted treatment. If the case were successful, these organizations could seek to change present laws and regulations allowing counties and states to charge an involuntary patient for unwanted treatment, with special attention paid to liens put on real and personal property.
It was observed that, in its role as the leading federal agency on mental health policy, CMHS has many direct and indirect opportunities to raise awareness about involuntary interventions. It was proposed that CMHS publish a position statement indicating that coercion represents a failure by the mental health system -- not a fault of the individual with mental illness -- and that involuntary interventions are emergency procedures to be used only briefly and avoided whenever possible.
Efforts are underway in some states to broaden the criteria for commitment or enable outpatient commitment. It was suggested that CMHS, in conjunction with NAPAS, fund a technical assistance project to involve consumer/survivors in opposing such changes in state law or regulations.
In order to draw attention to success in reducing coercive practices, CMHS or another national organization could create an award for the state mental health authority that has made the most progress each year in reducing coercive practices in their state, as well as identify states which failed or got worse.
CMHS could fund a national initiative to protect the access of patients in private psychiatric hospitals to protection of their civil rights.

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