Lisa Brophy

What's driving involuntary treatment in the community? The social, policy, legal and ethical context

Objective:Involuntary treatment in the community has become an increasing and accepted part of the landscape of mental health service delivery. Community Treatment Orders (CTOs) or Outpatient Commitment (OPC) may be understood to be an inevitable consequence of the process of deinstitutionalisation and an acceptance that many clients are at constant risk in the community and may require long-term involuntary treatment. However, there are important social, economic and political imperatives influencing CTOs; this article explores these driving forces and identifies the concerns of the critics of involuntary treatment in the community. Methods:Using the concept of force field analysis, the driving and restraining forces surrounding the development and implementation of CTOs are identified. Results: All Australian states and territories now have provision for involuntary community treatment. However, despite an increasing reliance on, and to some extent, acceptance of, the validity of involuntary community treatment in mental health, these developments are not uncontested. Consumer groups, legal advocates and service providers have questioned the use of involuntary treatment in the community and identified various concerns, including the potential for human rights abuses, ethical dilemmas and doubts regarding effectiveness. Conclusions: The paper concludes by arguing for stronger evidence base to support the use of CTOs. In doing so it focuses on the social, policy, legal and ethical context within which CTOs are implemented.

An international comparison of legal frameworks for supported and substitute decision-making in mental health services

There have been important recent developments in law, research, policy and practice relating to supporting people with decision-making impairments, in particular when a persons wishes and preferences are unclear or inaccessible. A driver in this respect is the United Nations Convention on the Rights of Persons with Disabilities (CRPD); the implications of the CRPD for policy and professional practices are currently debated. This article reviews and compares four legal frameworks for supported and substitute decision-making for people whose decision-making ability is impaired. In particular, it explores how these frameworks may apply to people with mental health problems. The four jurisdictions are: Ontario, Canada; Victoria, Australia; England and Wales, United Kingdom (UK); and Northern Ireland, UK. Comparisons and contrasts are made in the key areas of: the legal framework for supported and substitute decision-making; the criteria for intervention; the assessment process; the safeguards; and issues in practice. Thus Ontario has developed a relatively comprehensive, progressive and influential legal framework over the past 30 years but there remain concerns about the standardisation of decision-making ability assessments and how the laws work together. In Australia, the Victorian Law Reform Commission (2012) has recommended that the six different types of substitute decision-making under the three laws in that jurisdiction, need to be simplified, and integrated into a spectrum that includes supported decision-making. In England and Wales the Mental Capacity Act 2005 has a complex interface with mental health law. In Northern Ireland it is proposed to introduce a new Mental Capacity (Health, Welfare and Finance) Bill that will provide a unified structure for all substitute decision-making. The discussion will consider the key strengths and limitations of the approaches in each jurisdiction and identify possible ways that further progress can be made in law, policy and practice.

Impact of Care Coordination on Australia's Mental Health Service Delivery System

Care coordination models have developed in response to the recognition that Australias health and welfare service system can be difficult to access, navigate and is often inefficient in caring for people with severe and persistent mental illness (SPMI) and complex care and support needs. This paper explores how the Australian Governments establishment of the Partners in Recovery (PIR) initiative provides an opportunity for the development of more effective and efficient models of coordinated care for the identified people with SPMI and their families and carers. In conceptualising how the impact of the PIR initiative could be maximised, the paper explores care coordination and what is known about current best practice. The key findings are the importance of having care coordinators who are well prepared for the role, can demonstrate competent practice and achieve better systemic responses focused on the needs of the client, thus addressing the barriers to effective care and treatment across complex service delivery systems.

Attitudes towards seclusion and restraint in mental health settings: findings from a large, community-based survey of consumers, carers and mental health professionals

Aims. There are growing calls to reduce, and where possible eliminate, the use of seclusion and restraint in mental health settings, but the attitudes and beliefs of consumers, carers and mental health professionals towards these practices are not well understood. The aim of this study was to compare the attitudes of mental health service consumers, carers and mental health professionals towards seclusion and restraint in mental health settings. In particular, it aimed to explore beliefs regarding whether elimination of seclusion and restraint was desirable and possible. Methods. In 2014, an online survey was developed and widely advertised in Australia via the National Mental Health Commission and through mental health networks. The survey adopted a mixed-methods design, including both quantitative and qualitative questions concerning participants’ demographic details, the use of seclusion and restraint in practice and their views on strategies for reducing and eliminating these practices. Results. In total 1150 survey responses were analysed. A large majority of participants believed that seclusion and restraint practices were likely to cause harm, breach human rights, compromise trust and potentially cause or trigger past trauma. Consumers were more likely than professionals to view these practices as harmful. The vast majority of participants believed that it was both desirable and feasible to eliminate mechanical restraint. Many participants, particularly professionals, believed that seclusion and some forms of restraint were likely to produce some benefits, including increasing consumer safety, increasing the safety of staff and others and setting behavioural boundaries. Conclusions. There was strong agreement across participant groups that the use of seclusion and restraint is harmful, breaches human rights and compromises the therapeutic relationship and trust between mental health service providers and those who experience these restrictive practices. However, some benefits were also identified, particularly by professionals. Participants had mixed views regarding the feasibility and desirability of eliminating these practices.

Using Social Work Theory and Values to Investigate the Implementation of Community Treatment Orders

Abstract This paper establishes the value of a social work investigation of good practice with people on Community Treatment Orders in the context of social works longstanding interest in the ethical challenges of working with involuntary clients. The emancipatory values of social work were used to guide this research, thereby ensuring the participation of consumers and their families or carers. Critical social work theory provided an important theoretical base. A mixed methods approach was undertaken, including a cluster analysis and case studies. Five principles of good social work practice emerged from the qualitative data: (a) use and develop direct practice skills; (b) take a human rights perspective; (c) focus on goals and desired outcomes; (d) aim for quality of service delivery; and, (e) enhance and enable the role of key stakeholders. These principles are briefly presented along with recommendations for practice and service development.

Consumers’ and their supporters’ perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings

Objective This paper examines the perspectives of consumers and their supporters regarding the use of seclusion and restraint in mental health settings. Methods Five focus groups for consumers and five focus groups for supporters were conducted in four Australian cities and in one rural location. The 66 participants were asked about strategies to reduce or eliminate the use of seclusion and restraint in mental health settings. Results All participants supported the reduction of the use of seclusion and restraint. Barriers to reducing these practices related to the environment, the effects of drug and alcohol issues, lack of a human rights focus and poor recognition of trauma, stigma and discrimination. Strategies for reducing or eliminating seclusion and restraint included workforce development, environmental and cultural changes. Conclusions Participants clearly identified that the status quo needs to change and conveyed urgency for action. Participants suggested that the involvement of supporters and a range of consumer roles are integral to reducing the use of seclusion and restraint. The findings support the current policy emphasis of working towards the elimination of these practices. What is known about the topic? Mental health policies across many jurisdictions support the reduction and elimination of restraint and seclusion. Evidence suggests those subjected to restraint and seclusion largely experience a range of harmful consequences. No studies focus on the views of supporters of consumers regarding the reduction and elimination of seclusion and restraint, whereas the views of consumers appear in a minority of international studies. What does this paper add? The research enabled an opportunity to hear from people who have been personally affected by and/or have lived experience of these coercive practices. Participants identified local reforms that can uphold the human rights of consumers. They suggested practices to increase accountability, peer support and family involvement, areas that have not been analysed in depth in any of the seclusion and restraint literature. What are the implications for practitioners? This paper will give healthcare services a deeper insight into how to reduce or eliminate restraint or seclusion from the perspective of those with lived experience.

Dilemmas in the Case Manager's Role: Implementing Involuntary Treatment in the Community

Frontline non-medical practitioners in mental health services are frequently working as case managers with involuntary clients in the community who are subject to community treatment orders (CTOs). In this work they often experience tensions between the various legal and organisational expectations of their role, their professional orientation and wider understandings of social justice and consumer rights. This paper reviews literature on the purpose and efficacy of CTOs before discussing the current, limited role of the case manager within the Mental Health Review Board (MHRB) process in Victoria. In the concluding sections, it is argued that a more involved function for the case manager may enhance the decision-making process of mental health review tribunals.

Revocation of Community Treatment Orders in a mental health service network.

Objective: Community Treatment Orders (CTOs) require patients to co-operate with involuntary treatment in the community or risk having their CTO revoked and being readmitted to hospital. CTOs are used frequently in Australia. Their revocation has been under-investigated but is important because of the significant impact this process has on patients, families/carers and service-providers. This paper reports on an investigation of CTO revocations in a Victorian area mental health service in the period 2008–2010. Method: This was a mixed-methods study involving extraction of data from the Victorian statewide clinical database, a file audit and semi-structured group interviews with key stakeholders. Two different time periods were compared. Results: CTOs are commonly revoked within three months of discharge from the inpatient unit and multiple service-providers and family/carers have varying involvement that appears to depend on the timing of the referral to the Crisis Assessment and Treatment Team. Conclusions: The study identified opportunities for improving policy and practice, particularly in relation to reducing the amount of coercion experienced by people on CTOs and improving flexibility of service delivery.

Risk, Recovery and Capacity: Competing or Complementary Approaches to Mental Health Social Work

ABSTRACT Mental health social workers have a central role in providing support to people with mental health problems and in the use of coercion aimed at dealing with risk. Mental health services have traditionally focused on monitoring symptoms and ascertaining the risks people may present to themselves or others. This well-intentioned but negative focus on deficits has contributed to stigma, discrimination, and exclusion experienced by service users. Emerging understandings of risk also suggest that our inability to accurately predict the future makes risk a problematic foundation for compulsory intervention. Therefore it is argued that alternative approaches are needed to make issues of power and inequality transparent. This article focuses on two areas of practice: the use of recovery-based approaches, which promote supported decision-making and inclusion; and the assessment of a persons ability to make decisions, their mental capacity, as a less discriminatory gateway criterion than risk for compulsory intervention.

Embedding a Recovery Orientation into Neuroscience Research: Involving People with a Lived Experience in Research Activity

This paper highlights the importance and value of involving people with a lived experience of mental ill health and recovery in neuroscience research activity. In this era of recovery oriented service delivery, involving people with the lived experience of mental illness in neuroscience research extends beyond their participation as “subjects”. The recovery paradigm reconceptualises people with the lived experience of mental ill health as experts by experience. To support this contribution, local policies and procedures, recovery-oriented training for neuroscience researchers, and dialogue about the practical applications of neuroscience research, are required.