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”

APNA 27th Annual Conference Session 2014: October 10, 2013

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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

APNA 27th Annual Conference Session 2014: October 10, 2013

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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

timotm1@uw.edu

Jan Adam206-744-8256

jgadam@uw.edu

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

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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