What I Learned Part 2

Day Two of the American Academy of Psychiatry and the Law Conference

I picked up a number of tidbits from the poster sessions:

-250,000 juveniles a year are sent to the adult criminal just system
-3/4 of all juveniles serving life without parole were sentenced in five states
-Louisiana uses an assertive community treatment program to supervise and restore  incompetent, nondangerous criminal defendants. This sounds like a good way to get people out of the hospital, or avoid having to send them there in the first place
-In Indiana, a survey was done of judges who have dealt with defendants claiming to be “sovereign citizens.” Most appeared in court for traffic violations or fraud rather than violent offenses. Tax evasion was least common charge.
-In a survey of PGY4 general psychiatry residents, most felt confident in their ability to perform sanity and competency assessments. Fewer felt confident in their ability to assess malingering or to participate in civil commitment hearings. This is concerning.
-Specialized processing centers (SPC) have been built for ICE detainees. They have 24/7 psychiatric coverage and freedom of movement, but no clinical review or medication over objection procedures.

The Bazelon Center has filed suit with the Department of Justice over the American Bar Association requirement to disclose disabling conditions like psychiatric disorders on the bar application, and over the requirement for some lawyers to work provisionally under supervision solely due to  a history of psychiatric treatment. Proposed language to restrict questions about psychiatric issues is being considered.

The APA is updating its resource document on assisted outpatient treatment. The final document is not available at this time and the organization's position has also not be finalized.

There was an interesting talk by one of the people working on the development of the Stalking Risk Profile, a new instrument designed to predict the relative risk of continued stalking of one victim, the risk of stalking a new victim, and the risk of violence posed by a stalker. It has shown good interrater reliability based on the stalker typology, and good predictive validity between high and low risk offenders. (The overall recidivism rate was 15%, but almost all of that was due to stalking the same victim.)

The final session of the day was a panel presentation, with pro and con arguments, regarding whether involuntary non-emergency medication should be administered in a correctional rather than a hospital setting. The "pro" side noted that in some jurisdiction the waiting time to hospital transfer can be months long, and that appellate courts have upheld the use of these "Harper procedures" (after the SCOTUS case Washington v Harper) for pretrial detainees. The most creative argument on the "con" side was by Michael Perlin, who suggested that involuntary medication of prisoners was a violation of the Convention on the Rights of Persons with Disabilities (CRPD), an international human rights agreement which the United States has signed on to. He suggested that any kind of involuntary treatment or detention based solely on the presence of a mental disability was discriminatory and a violation of that document. A creative but not persuasive argument.

So that was Day Two.

What I Learned: Part 3

(Picture explanation to follow.)
Usually I write about the conference in the order that I hear things, but in this case I'm changing things around a bit to start with the topic I know most of our readers would be interested in. Involuntary treatment.

A Canadian nurse presented the results of a small but interesting study about the experience of being placed in a seclusion room. She developed a list of open-ended questions that she asked of both the nursing staff and secluded patients, 13 of each. Most of the patients who had been placed in seclusion had a psychotic illness, either schizophrenia or schizoaffective disorder. Five also had antisocial personality disorder.

Both groups were asked about the reasons for seclusion, their attitude toward the quality of care received while in seclusion, whether it was necessary and finally given the opportunity to describe the "ideal" seclusion room.

As expected, the nurses rated "safety" as the number one reason for use of seclusion, and none saw it as punishment. They emphasized that alternative interventions were always preferred and that extended negotiation was often used as a means of avoiding it. They emphasized the importance of having a good rapport in order to avoid escalation. Although the nurses were evenly divided on whether seclusion improved or impaired the quality of care given, most agreed that seclusion rooms could be beneficial in the short term for a patient's mental state. They reported feeling shaken and traumatized themselves when required to put someone in seclusion and said that debriefing with a colleague was helpful. They consistently emphasized the importance of a "QTIP" attitude ("quit taking it personally") when threatened or assaulted: "They could be cussing at you...spitting at you...hitting you. But you got to put all that aside because you know that's not the real person you were talking to the day before."

The surveyed patients had been placed in seclusion for an average of four or five days in the past six months. All but two patients had negative reactions to the experience and did not find the room beneficial for their mental states, although most understood the reason for the intervention. The experience was described in a wide variety of negative terms, but the most prominent theme was boredom. Two patients had positive reactions to the experience: relieved to avoid the stress of a potential confrontation with other patients, or even the opportunity to be "more creative" when left alone. The nursing protocol generally required the nurses to minimize patient stimulation and this meant that staff tried to minimize communication, and patients generally didn't like this. They were more likely to describe the experience as punitive, or used as an alternative to spending time with the patient. Lack of privacy, cold temperatures, difficulty with access to showers, soap and dental hygiene were also cited as a problem. Some patients were even served "finger food" rather than be trusted with utensils.

Both groups agreed that seclusion was a preferred alternative to physical restraints.

As a result of this study the group came up with recommendations to modify the physical conditions of the seclusion rooms, to provide more opportunities for interaction with staff while in seclusion, and to offer the option of listening to music.

This was the second presentation this week in which a project was organized and lead by a ward nurse, with resulting concrete recommendations to improve direct patient care. Nice.

Now to back up and discuss the poster presentations:

There was a survey of more than 600 Pittsburgh police drawn from all levels of service, including command staff and investigators. The purpose was to assess their attitudes toward the usefulness of mental health involvement in police matters. Most respondents rated crisis debriefing or personal counseling relatively low, but rated utility high for help with crisis or hostage negotiation. Interestingly, although most respondents weren't investigators (thus, had no direct experience with it) many rate "profiling" or investigative assistance as highly useful. About 25% of the respondents had been through CIT (crisis intervention training) and it was going to be made mandatory.

I'm a bit biased about the next poster since I know the investigator, but it's still a good one. It involved a battery of neuropsychology tests to look at which cognitive functions were most correlated with good or poor vocational outcomes. In other words, disability determination. Out of the entire battery, the strongest predictor was cognitive processing speed as measured by a simple paper and pencil test that took six minutes to administer. I thought this finding had intriguing potential for further study to look at correlations with general competence to stand trial.

There was a national survey of correctional mental health systems which tried to identify barriers to psychiatrist recruitment and retention. The most interesting part of this for me was the fact that anxiety or fear of the correctional environment was the biggest barrier to recruitment but the lowest factor for retention. That's consistent with my experience bringing new staff in to prison: after a few weeks you realize it's just not as horrible as everybody warned you it would be. (Or that journalists report.)

A poster about "Big Data" presented the results of a national survey of AAPL members regarding their use of Internet search data in clinical and forensic practice. About half regularly did Internet searches or reviewed social media related to their cases, and most have found useful information. Most thought there was a need for better guidelines for this practice given the ethical issues involved.

Today's session reflected ongoing concern about gun laws and firearm related violence. One poster presented the outcome of seven years of experience with a firearms seizure law in one Indiana county.  Court data from 2006 to 2012 was presented. During this time only 254 guns were seized. In the early years (2006 to 2007) most patients didn't bother to show up for their firearm retention hearing, or they voluntarily surrendered the weapon. In later years, courts dismissed the case and  returned the weapon in 80% of cases. The time to resolution of the case averaged 300 days. In two-thirds of cases, reason for seizure was threat of suicide and 3.5 weapons were recovered when the police transported the patient to the ER, voluntarily or involuntarily. In other words, the seizure law didn't take many weapons off the streets but it did make people more adamant about getting their weapons back. There was no data presented about suicide rates during this time.

At a panel discussion about gun laws since the Virginia Tech shooting I learned that in 1999, the first year that NICS (the background check system) went live, 81,000 firearms applications were denied (only 1.8%) and fewer than 0.1% were denied due to mental illness. By 2012, still only about 1% were denied but mental illness was the basis for 22% of the denials. I also learned that in order to take possession of a revoked weapon, police can only knock on the door and ask for the weapon. Apparently revocation does not serve as a basis for a search warrant. I hadn't thought about that issue.

Last but not least, there was a presentation on national laws related to zoophilia. (Thus, the turkey.) If you feel a need for dinner party trivia, I can tell you that 31 states have laws against zoophilia and that it could be either a felony or a misdemeanor. A LexisNexis search of cases using the term "zoophilia" turned up 26, usually in relation to an appeal of a sex offender commitment. The disorder was cited as a sign of generally more serious psychopathology in connection with other paraphilic disorders. I also learned about the practice of people known as "furries." If you want to know what that is, I will only tell you if you retweet a link to this post ten times:

Day 3 of the American Academy of Psychiatry and the Law, summaries here: http://t.co/ahtZbOfFeh #forensic #psychiatry #AAPL2013

— Clink Shrink (@clinkshrink) October 27, 2013

What Would You Do? What Would You Want?

Courtesy of CNN, here are a couple real-life scenarios I thought I'd share with you. Both of these videos represent the kind of cases that a psychiatrist confronts in an emergency room. I'd like you to put yourself first in the position of the patient: suppose you've been sick before, but never this sick (let's take it for granted none of this is due to drugs for now). You have an advance directive in place that says you absolutely don't want treatment even if you're a danger to yourself (again, for the sake of the exercise it's an enforceable advance directive). You never addressed danger to others in your advance directive because you never anticipated it could get this bad.

What would you want done?

If you were the doctor, what would you do?


Now for the second scenario. Is there anything about this situation that might make your wishes or opinions different from the first one? What's the difference? And if none, why not?



Thank you in advance for thinking about these problems. All of you who commented on my Emancipated Patient post have taught me something and I'm grateful. I'm putting this up to learn more about your ideas, opinions and wishes. Please keep talking.

The Emancipated Patient

  

On our last blog post pseudo-Kristen laid the groundwork for what I'm about to say. In a comment there she said:

"I want the same scenario as the cancer patient. I want to say, as someone who is presently competent to make decisions, that this form of intervention was not life saving for me, it was harmful to me personally and drove me further from care. I want to be able to opt out of all forced treatment in case of psychiatric emergency…"

Presently this isn't possible. Although psychiatric advance directives exist, the reaction I've gotten from both doctors and patients is that they are essentially useless. Doctors don't like them because they can lose the ability to give involuntary medications---leading to a patient taking up a hospital bed who can't be treated. Patients don't like them because in many states they can't be used to prevent civil commitment.

This got me thinking. What would happen if advance directives had teeth? What would be the outcome if certain patients, after a certain process, were essentially exempt from ever being subject to involuntary care?

There is an analogous process we can look to in juvenile law. (Forgive the comparison, I'm not implying that psychiatric patients should be or are lesser than adults although I'm sure sometimes it feels that way.)

In juvenile law, if someone can prove that he is living independently of his parents and is not financially dependent on them, or is married and raising a child, he may have himself declared emancipated by a judge. This essentially grants the chronological juvenile the same legal rights as an adult---he can sign contracts, consent or refuse medical treatments, and do other things not otherwise available to children.

Imagine a process by which a psychiatric patient could claim absolute treatment decision rights. He has perfect insight, has a reasonable understanding of what his illness is and what the symptoms are, the effects these symptoms have on his loved ones and employment, and all the possible ramifications of getting sick (yes, even the risk of suicide or criminal acts). Let's temporarily suspend all the obvious objections to this from family, psychiatry, and society in general and assume for the sake of discussion that such a process were magically adopted by the legislature.

Voila. You're free.

What happens next?

Ideally, nothing different. The patient gets better on his own or with the voluntary help of a mental health professional on either an outpatient basis or with a consenting inpatient admission.

Maybe he doesn't get better, but also doesn't want the "help." He struggles along on a daily basis, maybe functional or not-as-functional as he might be. Maybe he doesn't struggle along. He stops eating, stops bathing, stops drinking, loses weight and his family gets worried. He still doesn't want the "help."

Here's the point where everybody really starts getting nervous. The ugly question, the question not to be said out loud by any psychiatrist:

Should a psychiatric patient have the right to let himself die? (I feel a bit sick just writing that.)

At this point let me be clear that my own personal opinion is NO. This is only a theoretical discussion.

Now let's make things even more complicated. I'm going to draw on a real life, actual legal opinion for this hypothetical.

Before our hypothetical patient drew up his motion for emancipation he had to be assessed as competent to file for emancipation. Psychiatric advance directives have a similar requirement. But the Federal Court of Appeals for the state of Vermont has said that this is a violation of the Americans with Disabilities Act since medical patients don't have to prove competence before signing a medical advance directive. In Vermont, a theoretically incompetent person could sign an advance directive refusing all psychiatric care.

Personally I think a formal emancipation process would be better than taking that risk.

I could take this one step further and make the hypothetical even more extreme by pointing out that Vermont also just passed a law allowing physician assisted suicide (what if you want the right to die due to an terminal-if-untreated psychiatric condition?). I think I'll stop here for now. This slope is slippery enough.

Discuss.

What This Shrink Rapper Would Tell Congress

Recently one of our readers posted this comment:

“If any Shrink Rapper ever has the time and inclination it would be interesting to read about what you would do to fix the mental health system, particularly the issue of involuntary hospitalization, if you had unlimited funds and political resources. You've been in the trenches, it would be great to hear your thoughts.”

Simultaneously, over on Peter Earley’s blog I see that he is planning to testify next week before a U.S. house subcommittee regarding issues related to violence and severe mental illness. He is asking for people to contribute responses to six specific questions he expects to be asked. Please go over there and contribute your ideas---this is your chance to make a difference.

Meanwhile, I have my own thoughts about this which may or may not be directly relevant to the six questions, but I want to bring this to the attention of the subcommittee if Mr. Earley would be kind enough to include it. For those of you who want the "bottom line," I've underlined my main ideas.

First, a bit about why I think my experience and ideas are relevant.

As a forensic psychiatrist, I evaluate and treat severely mentally ill people who are or have been violent. I see the rare exceptions, the people who as a result of their disease commit acts that seriously injure or kill others. As a correctional psychiatrist I have also evaluated and treated thousands of prisoners, many of whom also have serious psychiatric disorders.

I will emphasize, as you've already heard from others, that violent offenses due to psychosis are the exception to the rule. Almost all crimes of violence are not committed by people with schizophrenia or other psychotic disorders. Drug and alcohol abuse is the culprit in most violent crimes and we must vigorously address this and do more to provide treatment to people with substance abuse problems at the time that they are willing to accept treatment.

From evaluating insanity acquittees, people who are found not criminally responsible for  their crimes due to mental illness, I’ve learned that one significant systemic problem is the lack of public awareness about psychosis and how to recognize prodromal symptoms. Often the early symptoms get written off as attributable to some other life stressor: the breakup of a relationship, the stress of a young adult's transition to college or some other understandable life event. Sadness, withdrawal from family, loss of interest in hobbies or friendships can be explained in this context. However, as the illness gets worse and the patient's personality changes, there is more recognition that something serious is going on. Friends, neighbors and teachers recognize psychosis only when there is increasing disorganization, inability to complete tasks, or eventual bizarre behavior and unusual statements.

Therefore, my first suggestion to address violence due to mental illness would be to provide better public education to recognize emerging psychosis.

Once the psychotic episode is recognized for what it is, the challenge for families then becomes figuring out what to do. Finding a psychiatrist and getting prompt evaluation and treatment is a tremendous challenge particularly in rural or underserved areas. In southwestern Minnesota where I was raised, there is only one fulltime psychiatrist serving a seven county area of 70,000 people. Our local Baltimore City Detention Center has a higher per capita number of psychiatrists than my hometown. That has to change.

My second recommendation is this: the government needs to provide increased funding for medical education, particularly the training of psychiatrists. There should be additional incentives, beyond Federal public health service commitments, to work in underserved regions or state facilities.

All of my patients are institutionalized but most will return to the community eventually. Insanity acquittees typically are hospitalized for substantially longer than they would have been incarcerated if convicted. The majority of my mentally ill offenders are convicted of misdemeanor property offenses that are drug or alcohol-related, and return to the community within months to a few years. Regardless of the length of confinement, we need better programs to transition patients from a public institution to the community. Insanity acquittees and mentally ill offenders need housing, transportation, educational and vocational programs in addition to addressing their medical and mental health needs. Lack of adequate community services and transition plans are a key factor in unnecessarily prolonged hospitalizations.

Many recent high profile crimes have lead the public to demand looser civil commitment standards and easing of laws for involuntary treatment. In my opinion, this creates an adversarial atmosphere and unnecessarily sets families in opposition to their mentally ill loved ones. People with psychiatric illnesses have legitimate reasons to oppose confinement, and we should examine these reasons thoroughly and address them.

Some public psychiatric hospitals, of the few that remain, are antiquated and dilapidated. We need to improve environmental conditions of these facilities and address the poor ventilation, bad plumbing and faulty infrastructure. The inpatient unit should emphasize treatment plans that respect a patient's educational level, skills and interests rather than focussing solely on disability. Inpatient safety and security are increasing concerns, leading some patients to be strip-searched arbitrarily. We must improve hospital security to protect both patients and staff from physical assault. As a recent story in our local newspaper indicates, concern about violence is not limited to free society and must be addressed within facilities as well.

Finally, we need to reinvigorate collaborative treatment planning through the use of psychiatric advance directives. Make them meaningful and useful. Currently patients don't trust them because they know doctors can override them. Ironically, doctors don't trust advance directives for exactly the same reason---because they can be revoked by patients. We need to update psychiatric advance directive laws to make them binding, effective and safe, then make sure treatment providers are educated about their use.

Thank you for reading this far. We can’t make the system perfect, but I’m sure we can make it better.

Texas: Never Too Sick for Death Row

Oy, if you're very sick and very dangerous, Texas is not the place to be. Oh, it never was and maybe it never will be.  

In Maryland, if someone is in the hospital and wants to leave, the vast majority of the time, they get leave.  If the staff thinks they should stay, they get to sign a leaving AMA form --against medical advice.  In rare instances, if a voluntary patient wants to leave, but they are felt to be imminently dangerous, then they can be certified, and held on the floor until there is hearing.  At the hospital where I did my residency, hearings were held on Wednesday when an administrative law judge came in for that purpose, so how long a patient was stuck there without 'due process' depended on what day of the week this went down.  In Texas, you can be committed against your will, but apparently as I've learned from yesterday's New York Times, if you've signed in, you can't be held and committed, no matter how sick, psychotic, and dangerous you are.  Really?  I'm back to my original thought: oy!

From Advocates Seek Mental Health Changes, Including the Power to Detain:

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it. 

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him. 

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them. 

He was on a mission from God, he said, to free their hearts of demons. 

What a travesty.   And here in Maryland,  yesterday a court sent a 15 year old boy, tried as an adult, to prison for life, commuted down to 35 years, for a school shooting / attempted murder.  The boy took his step-father's gun, which fortunately,  was not a rapid fire weapon, but a shotgun (I think), and before he could get too many rounds fired, a heroic teacher tackled him and the single wounded victim survived.  The boy left a suicide note, but his plan to die that day was foiled.  He's reportedly been improving with treatment in a county detention center, and he pleaded guilty to the charges, no insanity defense sought, no trial necessary, just a hearing for sentencing.  I won't comment on whether I think it serves society to send a child to prison with adults for 35 years.  

To those who oppose involuntary hospitalization under any conditions at all, I have to ask, what do you think should be done if you become so psychotic that you believe it's necessary to kill your own children and eat your own eyeballs?  In Texas, it's clear: you're free to do so and the state will just kill you. 

Tell Me What To Do

Note: As I was writing this post, Pete Earley reran a post he wrote in 2010 about this identical topic. Spooky! Please go over to his blog and read what he has to say about it here.

Now that states are moving to create registries of involuntarily admitted patients, I think the time has come to reconsider an old idea, specifically the use of of psychiatric advance directives (PADS).

For those who have never heard of this idea, a psychiatric advance directive is a form of durable power of attorney. It's a document that a patient creates which states the kind of treatment the patient would like in the future, if he becomes ill and loses the ability to make treatment decisions. The document may designate a person the patient wants to make decisions on his behalf---a person known as a health care proxy---or may just list the patient's wishes about various things. Here is a partial list of the issues that get addressed in a psychiatric advance directive:

- the choice of hospital the patient would like to be admitted to

- an affirmative statement requesting admission

- the types, frequency and dose of preferred medication

- consent for use of seclusion or restraint

- designation for care of children, property or pets

- person to notify or next of kin designation

- consent for use of electroconvulsive or ECT treatment

Of course, the obvious thing about this list is that there is an assumption that the person is using it to request treatment when ill, but it can also be used to document which treatments, if any, the patient wants to refuse.

But what if a patient uses an advance directive to refuse all treatment? Here likes the conundrum. What if the patient becomes violent or threatens someone else? What if the patient's condition deteriorates to the point that his life is in jeopardy? For example, someone who is catatonic and unable to eat or drink fluids? What if the patient is not dangerous or doing anything violent, but just needs supervision and nursing care (help bathing or dressing or eating) and can't live outside an inpatient unit? Should this person be allowed to stay in a hospital indefinitely (when there is a huge demand for psychiatric bedspace for voluntary patients) when a short course of involuntary medication might make them better enough to live independently, outside a hospital?

And what if the patient wants treatment, but the advance directive dictates a treatment that is experimental, ineffective, or even potentially harmful? Should an advance directive be allowed to contain a patient's request for medical marijuana? In some states, the treating psychiatrist is bound by law to follow the instructions in an advance directive and there are civil penalties for not following them.

Also, in certain cases an advance directive can be overridden by the court if the patient becomes dangerous to other patients. Depending on how the directive is written, it can also be revoked by the patient once he's in the hospital which makes the whole document rather pointless. Finally, many patients and doctors have either never heard of PADS or are not familiar enough with them to use them.

This is why I'm putting up this post now. I think the PADS have potential utility and are certainly better than the outpatient commitment laws that many states have (and that our state is considering). To keep things simple, let's start with the assumption that the patient actually wants to be treated when they are sick but loses the ability to make that decision. (In other words, the patient agrees with the treatment in retrospect---ie. "I didn't like it, but I know it had to be done.")

I'd like our readers to discuss this so we can figure out better ways to make them useful. Have you ever written or used a PAD (from either a psychiatist or patient standpoint)? What worked, what didn't? What would you like to see changed? How could it be improved? Do you have a better idea than a PAD?

If you want more information before commenting, here's a one-stop-shopping site for PAD information.