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Recovery Model: Mental Health Recovery Model Applied to Severely Mentally Ill; JH Rick Massimino MD

Recovery Model Analysis


THE CURRENT DAY ‘MENTAL HEALTH RECOVERY MODEL’ AS IT APPLIES TO THE SEVERELY AND CHRONICALLY MENTALLY ILL

The Identified Population

We will focus on the population of 'patients' known among psychiatrists as having 'treatment resistant psychosis' and 'treatment non-compliant psychosis'.  Today political correctness has nearly extinguished the use of these terms, but their meaning is more relevant than ever.  Psychotic patients who either refuse to accept treatment or are poor responders to treatment efforts are a major challenge to the clinical psychiatrist, a major concern for public safety, are living lives of desperation, creating desperation for their families/friends, consume the majority of our mental health dollars (acute hospital/emergency care), and have become the criminalized mentally ill occupying our jails, prisons and state mental hospitals.  The real and human costs associated with this tragic reality are beyond calculation, but one can conservatively speak in terms of billions of dollars with little to show for the expense.


The Stakeholders

Some of the stakeholders of the Mental Health Recovery Model include:  NAMI, patients with disabling schizophrenia/autism etc., judges and mental health courts, law enforcement, physicians/clinicians, tax payers, patient’s rights advocates, politicians, and concerned citizens.  Each stakeholder has an interest in our current mental health systems of care, and some accountability and responsibility for our longstanding failure to address the needs of this infirmed population.  


Historical Data

The chronically mentally ill have experienced the tragic historical evolution of institutionalization, followed by the era of deinstitutionalization, which led to the era of criminalization (jails, prisons, and state penal hospitals becoming long term treatment settings by default).  We have now entered the era of the Recovery Model, a concept born from the merged interests of substance abuse therapy philosophy and survivor/patients rights advocacy, both of which seem to distrust the Medical Model of care.

Current literature debates the clinical/medical concepts of recovery versus the social/rehabilitation concept of recovery (http://cme.medscape.com/viewarticle/518665).  Simply put, the 'recovery model’ promotes the concepts of hope, empowerment, self-direction, respect, responsibility, and peer support for building a meaningful life (http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/).  These important ideals, which should form a part of any good clinical medical/psychiatric treatment plan, dominate the recovery model’s person centered rhetoric to the exclusion of needed medical care (http://www.psychservices.psychiatryonline.org/cgi/content/abstract/57/5/640).  The consequence of this flawed thinking for the most severely mentally ill (those with defiance to treatment and unresponsiveness to medication) is that choice and self-determination are offered to those incapable of making healthy/correct choices.  Therefore, the result is a perpetuation of noncompliance to treatment and catapults this group towards hospitals, jails, prisons, and/or other dangers.  Ask any parent of a psychotic child “Can your child chose their correct treatment?” and you will understand why the mental health recovery model does not effectively serve the most severely mentally ill.  Practical concerns require better models of care to be created to reverse the current criminalization practices and allow for the release of the mentally ill into therapeutically effective residential settings.

In the recovery model, a lesser impaired and more verbal/opinionated subset of patients (those with substance abuse and/or mood disorders) has inadvertently and unconsciously become the voice of best practices for the seriously and chronically mentally ill.  Unfortunately, clinicians and administrators who are unwilling, disinterested, or unaware of how to successfully treat the most impaired, have embraced recovery ideals as if it were a genuine model of care. Until a “recovery model” is found and implemented which heals and effectively serves the most seriously mentally ill and disabled of our citizens, we are perpetuating an illusion of care and an almost unimaginable amount of pain and suffering on patients, their families, and our society.

Many people affected by chronic and disabling psychiatric conditions such as schizophrenia and autism can experience a social “recovery” from which degrees of independent life can be found even in the absence of medical cures or the extinction of symptoms.  Unfortunately, far too many of these individuals live lives of desperation and can be found incarcerated, homeless on our streets, or primarily unseen in the homes of families and caretakers throughout the world

Today, recovery has become a ubiquitous term.  Joseph Heller conceptualized ubiquitous as “ Plodded through the shadows fruitlessly like an ubiquitous spook”.  ‘Recovery’ has become the ubiquitous spook.


Involuntary Out Patient Treatment:  Solution or Starting Point?

Involuntary out patient treatment has been debated and defeated in the United States by the patient’s rights/recovery forces.  Other countries such as England (http://www.scotland.gov.uk/Publications/2007/09/03145057/0) have successfully implemented this concept.  Though a useful first step to providing needed treatment to the most seriously mentally ill, involuntary out patient treatment is an incomplete solution in light of the complex failings of the global mental health system.  A starting point for this discussion is the following analysis of the concepts of “imminent danger” and “good cause”.


Imminent Danger and Good Cause:  Two interdependent concepts that must be reexamined if we intend to reverse criminalization of the seriously mentally ill and release the incarcerated mentally ill into effective residential care

In 1967, the landmark California mental health law called LPS (Lanterman, Petris, Short) statute (Cal. W&IC 5000 et seq.) was created with the intention of reversing the longstanding legal and clinical abuses of institutionalization, which had been experienced by the seriously mentally ill.  LPS originally envisioned that an outpatient therapeutic environment would be created that would protect public safety as well as protect and treat the mentally ill.  Now, forty years later, we are experiencing the unanticipated negative consequences of failed policy, failed interpretations, and failed implementations.  In the attempt to correct the era of institutionalization, we created the era of de-institutionalization, which has resulted in the current era of criminalization of the seriously and chronically mentally ill.  How do we stop the criminalization from continuing and release those already victimized back into society?   

The seriously and chronically mentally ill as a group are at constant risk of returning to an institutional solution, as jails, prisons, and state penal setting have become the long-term treatment solutions by default.  The untreated chronically mentally ill, because of their impaired reasoning and poor reality testing, are more likely to commit crimes or be victimized and ultimately end up in the criminal justice system or worse.  Once in prison these individuals do not receive the mental health-care they need and become more ill.  They are then sent to a state hospital (the new asylum) for stabilization.  The dangerous behaviors of untreated psychosis, continually victimizes the patient and innocent bystanders, as is evidenced by frequent news reports (Virginia Tech) or the reality of the high numbers of the mentally ill in penal settings. 

Why hasn’t LPS been effective in meeting its original goals?  What went wrong?  What should we do now?

The solution may be so easy and simple in concept that it appears invisible to most.  To quote Ralph Waldo Emerson, “Nothing astonishes men so much as common sense and plain dealings”.  The solution can be found in re-examining two separate thoughts.  The first is the concept of imminent danger.  The second is the relationship between good cause criteria and an individuals right to refuse treatment and/or engage in behaviors which trigger relapse.

Consider the following vignette:  Police are called to a private family home because a previously diagnosed mentally ill person is expressing bizarre thoughts, behaving erratically, and scaring family members.  After a brief assessment by the police, the family is told by the officers, “We can’t do anything.  He is not yet sick enough.  He needs to hurt someone or break the law for us to act.”  In other words, the officer has determined that there is no imminent danger.  This scenario is played out in incalculable numbers all across the country everyday.  The rationale or criteria, which is used by the officers to make this statement and determination is called “Imminent Danger.”

What is imminent danger?  When officers of a police swat team were asked the meaning of “imminent danger” they unanimously said that imminent and immediate were synonymous.  No, this answer is incorrect!  An immediate danger is a present danger that is next in order and not separated by space or time.  An imminent danger is an anticipated danger that is likely to happen, is impending, and is separated by space or time.  For example, if a gigantic meteor that is certain to hit the Earth in a week’s time, it is not an immediate danger but it is certainly an imminent danger of life threatening consequence.  Is a psychotic person with distorted reality and aggressive unpredictable behavior an imminent danger?  Is a diagnosed individual who becomes psychotic without medication an imminent danger if their medication is stopped?  Every family member and every psychiatrist who has ever experienced these circumstances knows without any doubt that the answer is YES!  This circumstance is an imminent danger!  Therefore, law enforcement should intervene for both immediate danger and the imminent dangers that are separated by space and time.

Now we will address the concept of good cause.  Consider the following vignette:  Law enforcement is called to a residential group home for the seriously mentally ill due to the threatening behaviors of one of the residents.  When the police arrive the resident is calm.  Most people including the mentally ill know to behave in the presence of a uniformed officer or judge.  The police are told the resident has been refusing to take his medication.  The officer states, “I can’t do anything.  The resident is not an imminent danger and has the right to refuse medication.”  No, this answer is incorrect!  Not only is the resident an imminent danger, but the LPS statute included language which allowed for the curtailment of an individual’s right to refuse treatment based on a concept called “Good Cause.”  Good cause is a commonsense, scientifically based opinion rendered by an expert.  In other words, expert knowledge can anticipate that a patient who refuses to take their necessary medication will enter into a dangerous situation.  This expert opinion is the good cause criteria to curtail the patient’s right to refuse treatment.  Therefore, law enforcement with medical consultation should say, “You have an obligation to take your medication and refusing will result in a good cause curtailment of your personal rights”.  We use good cause criteria with other medical conditions that interfere with our abilities to be safe and good citizens.  For example, a person holding a restricted driver's license, which requires the use of corrective lenses, must wear them due to their inability to drive safely without them.  If that individual decides to drive without corrective lenses and is caught, they will be cited by law enforcement and could be restricted in their future right to drive.  Similarly, a patient who is clear thinking, on medication, and knows that refusing to take his/her necessary medication may result in a right restriction is far more likely to be cooperative, responsible, become a healthier citizen and act in his/her own best interest.

Attempting to explain why and how these incorrect interpretations of imminent danger and good cause criteria have evolved over the last forty years is impossible.  However, there is no doubt that the failed interpretation of imminent danger and the abandoned concept of, good cause right restrictions, are the root cause of the criminalization of the mentally ill.  At this moment in time when law enforcement makes physical contact with a seriously symptomatic mentally ill person, a critical decision is made.  The failure to accurately identify an imminent danger, which requires containment and treatment, leads the process astray.  When the ultimate and often delayed decision to arrest the mentally ill person is made, the opportunity to treat has already been lost.  This critical decision point is the genesis for the criminalization of the seriously and chronically mentally ill.  What happens after the arrest and the legal systems contribution to our failed mental health system is subject matter for a later discussion.  Perhaps the reason law enforcement chooses to allow an imminently dangerous person to remain free is because:

  • The officer knows that the mental health system is clogged and if the patient is placed on a 5150 (involuntary hold) he will be released almost immediately without receiving treatment.
  • By acting compassionately and honestly in assessing imminent danger, the officer will be removed from his primary duty to patrol the community because he will be obligated to baby sit until a hospital accepts the patient.  This can sometimes take many hours and even days.
  • The officer is respecting the individual’s right to refuse help and treatment by a severely disturbed mentally ill person believing it to be a constitutional right.  Yet a similarly emergent medical condition such as a traumatic injury or a heart attack would never prompt the question “Do you want to accept medical care?”
  • The officer is being expected to properly evaluate and make a disposition during a medical emergency without the proper training or knowledge needed for making such a decision.

Whatever the reason for the decision law enforcement makes to not intervene or alternatively to wait until a crime is committed and then arrest, society has placed police officers in an untenable position.  Law enforcement is too often the subject of our anger and frustration when our failed system is to blame.  We must all believe that we can change the course towards treatment with either voluntary or involuntary status, while respecting individual rights and human dignity, instead of continuing the current path toward criminalization.

The US Department of Justice has been systematically suing states and forcing the expenditure of  billions of dollars on the back-end of this problem: improving the care to the mentally ill in our prisons and state hospitals.  We should understand that the only way to fix this current tragedy of criminalization is by putting commonsense and good cause criteria into the front end of the problem and keeping people who should be in treatment settings out of prison or jail.  In November 2000, Richard R. Terzian, chairman of the Little Hoover Commission Report on Mental Illness said, “We spend billions of dollars dealing with the consequences of untreated mental illness – rather than spending that money wisely on adequate services.  We have in fact criminalized mental illness.  We have a moral and fiscal imperative to mental health reform.”  Was anybody listening then?  Is anybody listening now?

If we make a commitment to treatment instead of incarceration, we can then focus our energy, ideas and financial resources to build the front-end programs and services which are desperately needed: larger evaluation/triage/stabalization centers capable of managing complex psychiatric/medical conditions and residential programs which offer comprehensive integrated care and treatment philosophy consistent with the John Henry Model(c). Until we apply a reinterpreted and better understanding of imminent danger and good cause to our interventions with the seriously mentally ill, the change we urgently need will never be possible.


References:

Davidson, L., Lawless, M.S., & Leary, F.  (2005).  Concepts of Recovery: Competing or Complementary?  Current Opinion in Psychiatry.  18(6): 664-667.

Davidson, L., O'Connell, M., Tondora, J., Styron, T., & Kangas, K. (2006).  The Top TenConcerns About Recovery Encountered in Metnal Healht System Transformation.  Psychiatr Serv.  57:  640-645.

Healthier Scotland Scottish Executive.  (2007).  The New Mental Health Action:  An Easy Read Guide.  Retrieved from http://www.scotland.gov.uk/Publications/2007/09/03145057/0 on June 28, 2009.

SAMHSA’s National Mental Health Information Center.  (n.d.).  National Consensus Statement on Mental Health Recovery.  Retrieved from http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/ on June 28, 2009.

J.H. Rick Massimino M.D.