balancing risk & recovery.pdf

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Managing Risk and Recovery:Redefining Miscibility of Oil and Water

Marc Hillbrand, PhD, John L. Young, MD, and Ezra E. H. Griffith, MD

J Am Acad Psychiatry Law 38:452 6, 2010

Recovery is becoming a dominant emphasis in men-tal1 as well as in physical2 health care. It calls fordeliberate collaboration by clinicians with patients asempowered service consumers.3,4 As a model formental health care, recovery emphasizes a holistic

rather than a purely therapeutic approach and fo-cuses on the broader concern of the patients qualityof life rather than the narrow tableau of symptomreduction. It strives to prioritize the wishes of thepatient and that individuals autonomy.5A large in-ternational survey of patients, professionals, caregiv-ers, and advocates involved in institutional mentalhealth care identified 11 elements as being essentialto care. Their rankings of these components showeda strong consensus supporting the recovery model,beginning with quality of treatment and supportive-ness of staff members and including human rights,

self-management and autonomy, and institutionalenvironment.6 These striking results challenge once-dominant paternalistic values held by clinicians.

The change is most obvious on the inpatient psy-chiatric unit, where patients are expected to conformto the rules and dictates imposed on them. In thepast, their consent to treatment, let alone their col-laboration with clinicians, seemed irrelevant, sincethey were hospitalized for treatment of illnesses that

were seen as compromising or even precluding theircapacity to give such consent. Upon admission they

relinquished considerable autonomy automatically,

including their property rights and freedom of move-ment, association, and even of scheduling their timeand choosing their food.

No more. Psychiatric inpatients are expected totake an active role in determining many key aspects

of their treatment and their environment. From theday of admission they are called on to articulate theirgoals and expectations, prioritize their listing ofproblems, and collaborate in working toward theirexpeditious discharge. They are expected to weigh inon the selection and evaluation of treatment modal-ities, particularly medications. Caregivers no longerask so much whether the patient is following articu-lated medication regimens. Rather, the question is

whether the medications are delivering what the pa-tient wants from them.7 Reflecting this, the patient is

beginning to disappear from the literature authoredby some professional groups, replaced by theconsumer.

Such developments as these are now the well-recognized, widely accepted, and generally approvedresults of the so-called recovery movement in psychi-atry.8,9Although this recovery model is fitted to andconsidered efficacious in the civil inpatient setting, itremains out of place in the forensic inpatient unit. Ofnecessity, the restrictions and limitations imposed onthe patients autonomy far outstrip almost anythingfound in the civil inpatient unit before the recovery

movements influence. The impositions of the fun-damental concern for everyones safety principallyinclude scaled back property rights, limitations onmoving about, clothing restrictions including shoe-laces and belts, limitations on freedom of communi-cation, and diminished privacy.

Some newly admitted forensic patients experiencea particularly rude awakening, especially if they hap-pen to have had recent experience in the civil inpa-

All three authors are with the Department of Psychiatry, Yale Univer-sity School of Medicine, New Haven, CT, where Dr. Hillbrand isAssistant Clinical Professor of Psychiatry, Dr. Young is Clinical Pro-fessor of Psychiatry, and Dr. Griffith is Professor of Psychiatry and ofAfrican-American Studies. Dr. Hillbrand is also Director of Psychol-ogy, Connecticut Valley Hospital, Middletown, CT. Address corre-spondence to: Marc Hillbrand, PhD, Connecticut Valley Hospital,PO Box 351, Middletown CT 06457. E-mail: [email protected].

Disclosures of financial or other potential conflicts of interest: None.

452 The Journal of the American Academy of Psychiatry and the Law

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ing with the recovery model. Similarly, the team maydecide to see a few patients briefly to join in recog-nizing a birthday or other weighty anniversary, whilenoting whether the response suggests a concern forany increase in risks.

Of course, the need for an individual risk reassess-

ment may arise at any time. The major examples area dramatic worsening (or lifting) of mood, givingaway prized possessions, global insomnia, marked

withdrawal, looking for a fight one is sure to lose, andthe like.24 Such a situation calls for proactive forma-tion and application of an effective set of interven-tions. Most likely, there will be a focused addendumto the treatment plan, along with an update of theunits risk list. In keeping with the recovery model,the patients list of preferred approaches to stressshould be consulted (and updated if appropriate) astreatment plans are revised to address the episode.

Patients vary in their reactions to their experiencesof the recovery movements influence. Some of themrespond to it with cynicism because they know very

well that the legal emphasis on confinement for so-cietys safety determines their prospects for release.

At every legal hearing related in any way to release,the universal message is that no matter how muchcaring encouragement and quality treatment theymight receive, it is up to them to eliminate or at leastgain control of their risk factors for violence. Often itis legitimate for them to feel that this emphasis is on

the increase. The recovery message also seems ques-tionable when peers whom they know well from liv-ing together and who seem at least equally at risk foraggressive behavior are allowed to leave, usually dueto legal reasons that patients often fail to appreciate.

Others may choose to express their cynicism bytaking advantage of the opportunities to exercisetheir rights to decide important aspects of their treat-ment. They may decide to refuse medication becauseof side effects and withhold their cooperation withthe therapeutic groups that they need most. Theymay move a few of their peers to behave similarly.

Some may also take advantage of the opportunity tomake excessive complaints.

Despite the inevitable cynics, we are finding thatfor most patients, encouraging a culture of recoveryleads to improved quality of life for patients and staffmembers alike and with it the quality of care. Giventhe opportunity, patients are eager to generate prac-tical ideas for improving their environment and joinin making the necessary efforts, including challeng-

ing appropriately their cynical colleagues. They en-joy assembling to hear the stories told by peers whohave been released and are brought back for struc-tured visits. They have worthwhile suggestions forcreating a variety of therapy groups. Some of theseideas might be recreation disguised as therapy; others

are all the more effective because some of their needsare best appreciated by the patients themselves. Theyfind encouragement to pay attention to others, to beresponsibly creative, and to learn from experience.Staff members should be encouraged to join in thecreation and leadership of therapy groups, with ap-propriate supervision as part of the encouragement.

Although the concepts related to the recoverymovement continue to undergo refinement,25 thereis growing agreement on such components as sup-porting hope, celebrating small gains, emphasizingmedication choice and effectiveness more than ad-herence to the regimen, pursuing goals as the patientdefines them, and supporting helpful initiatives cho-sen by patients.7Although they may initially appearlike oil and water, there is a growing sense that therecovery model may be readily compatible with evi-dence-based practices.9 Our experience as recountedhere suggests that it may be likewise miscible with thedemands of the high-security inpatient setting. Whatis needed for this is the development of a culture ofrecovery that can enable clinicians to focus appropri-ate attention on managing risks while still viewing

the patient as a whole person, a unique individualwith likes and dislikes, strengths and weaknesses, try-ing to get various needs met. Nevertheless, we recog-nize that respecting and promoting patient auton-omy at times conflict with interventions that areneeded to mitigate directly the risks of suicide andaggression. Autonomy also conflicts with the realityof mandated treatment. The treatment of insanityacquittees,26 end-of-sentence felons with severe psy-chiatric disabilities,27 and sex offenders28 involvesthe management of risk and has tended to pay littleheed to the autonomy of these individuals. Nonethe-less, we believe that a culture of recovery-orientedclinical care could contribute to the promotion ofrisk reduction for forensic inpatients, regardless oftheir legal classification.

References

1. Young AS, Chinman M, Forquer SL,et al: Use of a consumer-ledintervention to improve provider competencies. Psychiatr Serv56:96775, 2005

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2. Jennings D: Healing physically, yet still not whole. New YorkTimes. January 19, 2010, p D5

3. Simon RI: Postmortem assessment of suicide risk factors at thetime of death. J Forensic Sci 43:111923, 1998

4. Schetky DH: Mission impossible. J Am Acad Psychiatry Law26:38391, 1998

5. Connecticut Department of Mental Health and Addiction Ser-vices: Standards of Practice for Recovery-Oriented Behavioral

Health Care. Hartford, CT: Author, 20046. Turton P, Wright C, White S: Promoting recovery in long-terminstitutional mental health care: an international Delphi study.Psychiatr Serv 61:2939, 2010

7. Diamond RJ: How to support recovery for people with mentalillness. Psychiatr Serv 60:1155, 2009

8. Turner-Crowson J, Wallcraft J: The recovery vision for mentalhealth services and research: a British perspective. Psychiatr Reha-bil J 25:24554, 2002

9. Davidson L, Drake RE,SchmutteT, et al: Oil and water oroil andvinegar?evidence-based medicine meets recovery. CommunityMent Health J 45:32332, 2009

10. Institute of Medicine: Crossing the quality chasm: a new healthsystem for the 21st century. Washington, DC: Author, 2001.Available at http://www.nap.edu/books/0309072808/html. Ac-

cessed August 28, 201011. Mann J, Apter A, Bertolote J,et al: Suicide prevention strategies:a systematic review. JAMA 294:206474, 2005

12. Centers for Disease Control and Prevention: Web-based InjuryStatistics Query and Reporting System (WISQARS). Fatal In-jury Reports. Available at http://www.cdc.gov/injury/wisqars/index.html/. Accessed August 28, 2010

13. The Joint Commission: Inpatient Suicides: Recommendationsfor Prevention. Issue 7. November 6, 1998. Available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_7.htm. Accessed August 30, 2010

14. Simon RI: Suicide risk: assessing the unpredictable, in Textbookof Suicide Assessment and Management. Edited by Simon RI,Hales RE. Washington, DC: American Psychiatric Publishing,2006, pp 132

15. Berman AL: Risk management with suicidal patients. J Clin Psy-chol 62:17184, 2005

16. Ennis BJ, Litwack TR: Psychiatry and the presumption of exper-tise: flipping coins in the courtroom. Cal L Rev 62:693752,1974

17. Faust D, Ziskin J: The expert witness in psychology and psychia-try. Science 241:315, 1988

18. Webster CD, Ben-Aron MH, Hucker SJ, eds: Dangerousness.

Cambridge, UK: Cambridge University Press, 198519. Simon RI, Tardiff K (editors): Textbook of Violence Assessmentand Management. Washington, DC: American Psychiatric Pub-lishing, 2008

20. PinardGF, Pagani L (editors): Clinical Assessment of Dangerous-ness. Cambridge, UK: Cambridge University Press, 2001

21. Hall HV, Ebert RS: Violence Prediction. Springfield, IL: CharlesC Thomas, 2002

22. Maden T: Treating Violence. Oxford, UK: Oxford UniversityPress, 2007

23. Hillbrand M, Forman S, Lamb-Pagone J: Benefits of electronicmedical records in suicide risk management. Behavioral Emergen-cies Update. Newsletter of the American Psychological Associa-tion. Spring-Summer, 2008, pp 57

24. American Association of Suicidology: Recognizing and Respond-

ing to Suicide Risk: Essential Skills for Clinicians. Washington,DC: Author, 200725. Liberman RP, Kopelowicz A: Recovery from schizophrenia: a

concept in search of research. Psychiatr Serv 56:73542, 200526. Simon RI: Suicide risk assessment: what is the standard of care?

J Am Acad Psychiatry Law 30:340 4, 200227. United Kingdom Department of Health: Safety first: five-year

report of the National Confidential Inquiry into suicide and ho-micide by people with mental illness. London: National HealthService, 2001. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_062848. Accessed August 30, 2010

28. Cassells C, Paterson B, Dowding D,et al: Long- and short-termfactors in the prediction of inpatient suicide: a review of the liter-ature. Crisis 26:5363, 2005

Managing Risk and Recovery

456 The Journal of the American Academy of Psychiatry and the Law

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