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APNA 27th Annual Conference Session 2014: October 10, 2013
Meeks, Adam 1
UW MEDICINE │ American Psychiatric Nurses Association Annual Conference 2013
THE ELEPHANT IN THE ROOM:
RECONCILING RECOVERY PRINCIPLES WITH
FORCED TREATMENT
TIMOTHY MEEKS & JAN ADAMOCTOBER 10, 2013
The speakers have no conflicts of interest to disclose.
Harborview Medical CenterSeattle, Washington
THE ISSUE
Recovery Principles (RP) have become a treatment standard in psychiatric nursing:
• Pittsburgh APNA Annual Conference
• Recovery “camps” are forming
• Conflicting views of recovery
• Definitions are in flux
• Involuntary patients
• RPs and forced treatment
LEARNING OBJECTIVES
• Describe 2 ways that RPs can be incorporated into forced treatment.
• List 3 positive outcomes that can result from incorporating recovery-inspired treatment into involuntary care.
• Discuss how political, economic, and social conditions have influenced the recovery paradigm.
APNA 27th Annual Conference Session 2014: October 10, 2013
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RECOVERY
• Deinstitutionalization
• Consumer movement began in the 70’s
• Alcoholics Anonymous
• Research: Harding et al. (1987)
• SAMSHA, NAMI, APA, APNA
(Anthony, 2000; Moller & McLoughlin, 2013)
RECOVERY TIMELINE
• 1970: Women’s, gay rights, & disability rights movements
• 1970: Insane Liberation Front• 1978: On Our Own: Patient
Controlled Alternatives to the Mental Health System
• 1979: NAMI (WI)• 1981: 1st National Consumer
Conference (WA)• 1992: Mary Ellen Copeland-
WRAP• 2004: SAMHSA Consensus
Statement
Judi Chamberlin (1944-2010)
RECOVERY CONCEPTS
• Hope
• Self-Determination
• Strengths-Based
• Choice
• Collaboration
• Compassion
• Personal Responsibility
• Social Context
• Consumer Involvement
APNA 27th Annual Conference Session 2014: October 10, 2013
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THE DETRACTORS
• Recovery is a white, middle-class, Western construct
• Marginalizes those who don’t fit
• Recovery and psychiatric symptoms are mutually exclusive
• Not evidence-based
• Gives false hope to those who don’t recover
• RPs allow patients to avoid needed treatment
• Ignores economic realities
(Davidson et al., 2006; Fernando, 2008)
POLITICAL & ECONOMIC FACTORS
The “Perfect Storm”
• Billions cut from state mental health budgets
• More individuals seeking care
• Decreased number of psychiatric beds
• Washington State in crisis
• Voluntary admissions more difficult
• Increased patient acuity
(Glover, Miller, & Sadowski, 2012; Honberg, Kimball, Diehl, Usher, & Fitzpatrick, 2011; Smith, 2011; Whiteaker, 2013).
• Should patients guide their own care?
• When is treatment necessary?
• Patient rights vs. community safety
• Legal considerations
• Ethical considerations
• Case study: Cafe Racer
THE NEWS, THE MEDIA, AND RECOVERY
(Goode, Kovaleski, Healy, & Frosch, 2012; Gordon, 2013; Halbfinger, 2012; Santora, & Hartocollis, 2012; Stawicki, 2013)
APNA 27th Annual Conference Session 2014: October 10, 2013
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SAFETY AND SECURITY
• Self-determination vs. community safety
• Balance goals of person and community expectations
• Treatment focus is on preventing harm• Patient-centered care
PHILOSOPHIES OF FORCED TREATMENT
• Mental Health America
• SAMHSA
• National Alliance on Mental Illness
• Bazelon Center for Mental Health Law
• Treatment Advocacy Center
(Mental Health America, 2010; Public Policy NAMI, 2013; SAMSHA, 2012; Where We Stand, n.d.)
FORENSIC OR CIVIL COMMITMENT
Do individuals with mental illness belong in jail?
• Laws vary by state
• Involuntary medications
• Lack of treatment
• Victimization
• Community safety
• Recovery in forensic settings
APNA 27th Annual Conference Session 2014: October 10, 2013
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ETHICAL CONSIDERATIONS
Involuntary treatment:
• First step to recovery
• Moral obligation
• Prevent human suffering
• Respect for persons
• Human dignity
• Restraints and recovery
“If a person with serious mental illness becomes psychotic and dangerous, how can one honor the principles of recovery-oriented practice to achieve recovery goals without use of involuntary interventions?” (Geller, 2012)
RECOVERYHope Choice
Patient
Caregiver
RECOVERY ON AN INVOLUNTARY UNIT
• Recovery as process
• Staff training
• Strengths-based
• Incorporates patient goals
• Focus on teaching skills
• Patient education
• Increase tolerance for aberrant behavior
• Think “outside the box”
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CARE AND COLLABORATION
• There is always a choice
• Provide opportunities for collaboration
• Involuntary hospitalization offers treatment opportunities
• “No” is an option
• Raise the bar—expect more Choice
ADELLE
• 30 year-old transgendered woman
• Jumped from a bridge breaking both legs
• Schizoaffective & borderline personality disorders
• Easily agitated
• Persecutory delusions
• Disruptive to the milieu
• Patients have threatened to harm her
HOPE
• Each hospitalization is an opportunity for
recovery
• Share patient stories
• Provide perspective
• Lead by example
• Use peers
Hope
Hope
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Hope
HopeHope
HopeHope
Hope
Hope
Hope
Hope
Hope
Hope
HopeHope
HopeHopeHope
Hope
Hope
Hope
Hope HopeHopeHope
Hope
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PEER BRIDGER PROGRAM
• Works collaboratively
with patient and
providers
• Treatment team member
• Involved in discharge
planning
• WRAP
• Support 30-90 days after
discharge
• Medication support
• Illness self-management
Picture of Peer Bridgers
OUTCOMES
• Conveys respect
• Improves therapeutic alliance
• Empowers patient
• Decreases power struggles
• Increases patient & staff satisfaction
MATT
• 36 year old male
• Homeless
• Paranoid schizophrenia
• Selectively mute
• Refusing PO medication
APNA 27th Annual Conference Session 2014: October 10, 2013
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MANY VOICES, ONE GOAL
• Different facilities, different patients, same goal• Involuntary hospitalization can be first step to
recovery• Involuntary treatment can be patient-centered• Involuntary treatment often requires more provider
involvement• Basic recovery principles are the same
1. Recovery principles can be incorporated into forced treatment by:
a. Offering choices
b. Collaborating
c. Providing peer support
d. All of the above
2. Caregivers should refrain from using principles of recovery when:
a. Compelling medications
b. Secluding or restraining a patient
c. Discussing mandated treatment
d. Never
POST TEST
3. Current political, economic, and social influences have made the application of recovery principles more challenging because:
a. Increased social acceptance for patient self-determination
b. There has been a decrease in psychiatric beds
c. Decreased funding has resulted in fewer community-based resources
d. Both b and c
4. Positive outcomes from using recovery principles in involuntary treatment are:
a. Improves the nurse-patient therapeutic relationship
b. Empowers patients
c. Shows respect
d. All of the above
POST TEST CONT’D
APNA 27th Annual Conference Session 2014: October 10, 2013
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CONTACT INFORMATION
Timothy Meeks206-744-8254
Jan Adam206-744-8256
REFERENCESAnthony, W. A. (2000, Fall). A recovery-oriented service system: Setting some system level standards. Psychiatric Rehabilitation Journal, 24(2), 159-168.
Copeland, M. E. (1997). Wellness Recovery Action Plan. Dummerston, VT: Peach Press.
Davidson, L., Lawness, M. S., & Leary, F. (2005). Concepts of recovery: Competing or complimentary? Current Opinion Psychiatry CME, 18(6): 664-667.
Davidson, L., O’Connell, M., Tondora, J., Styron, T., & Kangas, K. (2006). The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services, 57(5), 640-645.
Davidson, L., & Roe, D. (2007). Recovery from versus recovery in serious mental illness: One strategy for lessening confusion plaguing recovery. Journal of Mental Health, 16(4), 459-470.
Fernando, S. (2008, January/February). We Shall Overcome! Openmind, 149, 25.
Geller, J. (2012), Patient-centered, recovery-oriented psychiatric care and treatment are not always voluntary. Psychiatric Services, 63(5), 493-495.
Glover, R. W., Miller, J. E., & Sadowski, S. R. (2012). Proceedings on the state budget crisis and the behavioral health treatment gap: The impact on public substance abuse and mental health treatment systems [Policy brief]. Retrieved from National Association of State Mental Health Program Directors website: http://www.nasmhpd.org/docs/Policy/SummaryCongressional%20Briefing_2012.pdf
Goode, E., Kovaleski, S., Healy, J., & Frosch, D. (2012, August 26). Before gunfire, hints of ‘bad news’. The New York Times. Retrieved from http://www.nytimes.com/2012/08/27/us/before-gunfire-in-colorado-theater-hints-of-bad-news-about-james-holmes.html?pagewanted=all
Gordon, C. (2013, February 2). Letter. Sunday dialogue: Treating the mentally ill. The New York Times. Retrieved from http://www.nytimes.com/2013/02/03/opinion/sunday/sunday-dialogue-treating-the-mentally-ill.html?src=xps&pagewanted=all
Halbfinger, D. M. (2012, December 14). A gunman, recalled as intelligent and shy, who left few footprints in life. The New York Times. Retrieved from http://www.nytimes.com/2012/12/15/nyregion/adam-lanza-an-enigma-who-is-now-identified-as-a-mass-killer.html
Harrison, G., Hopper, K., Craig, T., Laska, E., Siegel, C., Wanderling, J., ... Wiersma, D. (2001). Recovery from psychotic illness: A 15- and 25-year international follow-up study. British Journal of Psychiatry, 178, 506-517.
Honberg, R., Kimball, A., Diehl, S., Usher, L., & Fitzpatrick, M. (2011). State mental health cuts: The continuing crisis. Retrieved from NAMI, the National Alliance on Mental Illness website: http://www.nami.org/ContentManagement/ContentDisplay.cfm?ContentFileID=147763
Kelly, M., & Gamble, C., (2005). Exploring the concept of recovery in schizophrenia. Journal of Psychiatric and Mental Health Nursing,12, 245-251.
Meehan, T., King, R., Beavis, P., & Robinson, J. (2008). Recovery-based practice: Do we know what we mean or mean what we know? Australian and New Zealand Journal of Psychiatry, 42, 177.
Mental Health America (2010). Position statement 22: Involuntary mental health treatment. Retrieved from http://www.mentalhealthamerica.net/go/position-statements/22
Moller, M. D., & McLoughlin, K. A. (2013, May/June). Integrating recovery practices into psychiatric nursing: Where are we in 2013? Journal of the American Psychiatric Nurses Association, 19(3), 113-116.
Onken, S., Craig, C., Ridgway, P., Ralph, R., & Cook, J. (2007), An analysis of the definitions and elements of recovery: A review of the literature. Psychiatric Rehabilitation Journal, 31(1), 9–22.
Schrader, J. (2013, March 10). Fewer beds for mental-health patients. The News Tribune.
Smith, C. (2011, March 9). Budget cuts rip through mental health safety net in state. Investigate West. Retrieved from http://www.invw.org/content/budget-cuts-rip-through-mental-health-safety-net-in-state
Whiteaker, C. (2013, January 22). Mental Health [Issue brief]. Retrieved from Washington State Hospital Association website: http://www.wsha.org/files/65/MentalHealth.pdf
Mental Health America; (2010), Position Statement 22: Involuntary Mental Health Treatment
REFERENCES, CONT’D
APNA 27th Annual Conference Session 2014: October 10, 2013
Meeks, Adam 10
Public policy platform of NAMI: The national alliance on mental illness [Public policy statement]. (2013). Retrieved from http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Public_Policy/NAMI_Policy_Platform/PublicPolicyPlatformupto7.16.13MASTER.pdf
Roberts., G., & Wolfson, P. (2004). The rediscovery of recovery: open to all. Advances in Psychiatric Treatment,10, 37-49.
SAMHSA’s working definition of recovery updated. (2012). Retrieved August 2, 2013, from http://blog.samhsa.gov/2012/03/23/defintion-of-recovery-updated/
Treatment Advocacy Center (2007). Victimization: One of the consequences of failing to treat individuals with severe psychiatric disorders [Backgrounder]. Retrieved from http://www.treatmentadvocacycenter.org/storage/documents/pdfbpvictimization.p
Treatment Advocacy Center (2011). Violent behavior: One of the consequences of failing to treat individuals with severe mental illnesses [Backgrounder]. Retrieved from http://www.treatmentadvocacycenter.org/storage/documents/violent-behavior-backgrounder.pdf
Stawicki, W. (January 5, 2013). Mental illness and violence — what must change in Washington state [letter to the editor]. The Seattle Times. Retrieved from http://seattletimes.nwsource.com/html/opinion/2020061391_waltstawickiopedxml.html
“Victimization: One of the consequences of failing to treat individuals with severe mental illness”, Treatment Advocacy Center, March 2011,
Where we stand: Self-determination. (n.d.). Retrieved from http://www.bazelon.org/Where-We-Stand/Self-Determination.aspx
Whitwell, D., (1999). The myth of recovery from mental illness. Psychiatric Bulletin, 23, 621-622.
REFERENCES, CONT’D
PHOTO CREDITS
Harborview Medical Center: public domain
James Holmes: public domainErika Menendez: NYPD, public domain
Jared Loughner: public domainGathering Storm Clouds: Bill Koplitz from the FEMA photo library, public domain
Elyn Saks: www.ted.comFred Frese: http://www.namicalifornia.org/
Eric Arauz: www.apna.orgVue d’un chemin en foret: Hermes from mars (wikimedia commons)
Judi Chamberlin: Tim Olin, MindFreedom International (wikimedia commons)Handcuffed man: Lionel Allorge (wikimedia commons)
Caring Success: Roy Blumenthal (wikimedia commons)Man in silhouette: Abhaipratap (wikimedia commons)A young man’s dreadlocks: Giovanni Dall'Orto (wikimedia commons)
Crowd: James Cridland (wikimedia commons)Colours of Happiness: Camdiluv (wikimedia commons)
Choice: Duncan Lilly (wikimedia commons)Picture of peer bridgers: Tim Meeks
Norm Maleng Building: Tim Meeks