On Our Way: Recovery News Vancouver Acute & Community Mental Health Services Volume 1, Issue 4
March 2010
Hope Goal-Directed Self-Determination Awareness & Potentiality Meaning & Purpose
From the editor:
Recovery & Extended Leave Welcome to the fourth edition of “On Our Way: Recovery News”. The theme for this issue, extended leave, was inspired by questions submitted to us by a family member. For those of you who aren’t sure what extended leave means, it is a form of forced treatment in the community that is sometimes also called outpatient committal. A person is required to receive treatment or be sent back to hospital. We think the topic of extended leave and how it does or does not relate to recovery is so complex that we wanted to devote most of an issue of our newsletter to exploring it from the viewpoint of service providers, family and people with experience being on extended leave. On a personal note, it was interesting to me that this topic came up because I have been on extended leave myself. I will be sharing my thoughts with those of others. But extended leave is not all this newsletter will cover. We’ve also included an article on Healing Touch and an article on Microaggressions in Mental Health, plus an update about Spiritual Work, and “Words of Wisdom” about recovery. As always, we welcome your articles, letters and ideas on topics related to recovery. Please send to renea.mohammed@vch.ca. Happy Reading!
Extended Leave: An Overview By Simon Davis
“Extended leave” is a provision in the BC Mental Health Act that authorizes mandatory attendance at, and treatment by, a community psychiatric clinic. Usually, when talking about “certification” and involuntary treatment, we are referring to inpatients at the psychiatric unit of a hospital; however, with extended leave, the involuntary status of an inpatient is extended past the person’s release from the hospital. Extended leave, or a variation of the same, exists in all Canadian jurisdictions, other Commonwealth countries, and most U.S. states, although these may go by different names, such as “community treatment order.” In B.C. extended leave can only be initiated at hospital, whereas in Ontario and Saskatchewan there are provisions for initiating the order in the community. Currently there are approximately 380 clients on extended leave among the Vancouver mental health teams.
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Extended Leave: An Overview continued… Why do we have extended leave? According to the Ministry of Health’s Guide to the Mental Health Act (which is available free on-line at: http://www.health.gov.bc.ca/library/publicat ions/year/2005/MentalHealthGuide.pdf), extended leave is “suitable” for a person who: • requires reinforcement of, or support for, compliance once out of the hospital, and • has had repeated relapses as a result of repeated non-compliance with medication and other care arrangements, and/or • exhibits non-compliance which is intentional and/or due to lack of insight into the nature and severity of his/her illness. In short, extended leave was designed to stop the “revolving door” of hospital readmission resulting from persons going off their psychiatric medication. The Guide also states that extended leave should only be used when the client “will be provided appropriate services in the community” (which could be a problem in more remote areas, for example), and “should not be used to reduce a patient’s length of stay in hospital when the patient is still in need of inpatient care” (which can be a problem if there is a shortage of, and pressure on, psychiatric beds). Extended leave is controversial because it deprives people of some basic civil rights. In a famous essay, English philosopher John Stuart Mill argued that, no matter how wellintentioned, interventions by the state which deprived people of their liberty led to the infantilization of its citizens, and had to be justifiable. Justifications for the use of extended leave include the arguments that:
Page 2 short-term limits on autonomy enable people to exercise greater liberty in the future; • once treated, clients in retrospect agree that certification was in their best interests (a finding made in a number of surveys); • extended leave is by definition “less restrictive,” since the person is in the community, not in a hospital. On the other hand, critics of extended leave suggest that: • it is disempowering, and supports the tradition of medical paternalism; • it reinforces stereotypes of the mentally ill as dangerous, leading to more stigma and marginalization (“leash laws”); • it hurts the therapeutic relationship and alienates clients from treatment programs, since the clinician monitoring the extended leave is in effect a probation officer. Another concern has to do with the inference that non-adherence to a medication regimen is necessarily due to “lack of insight.” While a minority of clients seen in community programs may never understand a need to be on medication, most are capable – with support and guidance from clinical staff – of exercising informed consent. Concerning the unwanted effects of medication, consider the dilemma of an extended leave client being required to take antipsychotic drugs that may cause weight gain and lead to type II diabetes. How do people get off extended leave? In most cases they are discharged by the community doctor, and usually this is after a relatively short period – months, as opposed to years. Individuals may also appeal their detention once every renewal period (three to six months) through a “review panel,” where a three-person panel determines whether the certification criteria still apply. It is recommended that clients use an •
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Extended Leave: An Overview continued… advocate for this process, which can be provided at no cost through the Community Legal Assistance Society. Even without the client requesting it, there is an automatic review of the extended leave once a year through the review panel office. Clients may also request a second opinion about treatment while on extended leave. Reconciling involuntary or coercive treatment with a recovery perspective is not an easy matter, and this brief summary does not pretend to offer any quick solutions. It seems fair to say that the use of coercion should be minimized and alternative strategies adopted as much as possible. Clinicians need to be reflective about aspects of practice that, while perhaps unintended and less obvious, are nonetheless disempowering. And, dialogues between clinicians, consumers, and family members on this important matter need to continue.
Did You Know? There’s a great website on brain fitness featuring articles, resource information and brain games. Check out: http://www.sharpbrains.com/
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Words of Wisdom
"Recovery is living one day at a time. It is building new dreams, making new understanding friends and learning to live within my abilities. Recovery is spending the time to heal and become whole once again." - Anita Smith “The main thing to remember is that you should never give up and the help is out there. It took me 8 months to find the "right" help for me, and I did it by networking. I was isolating myself and staying home, but not getting any better. So no matter how you feel, get out and do stuff.” - Wendy Porter “Acceptance of having mental illness is the first step towards healing. Once the denial is gone, then the person can go about making the necessary steps required to stabilize the mental illness. Finding the correct medication and taking them regularly is vital to recovery. A healthy diet, drinking lots of water, proper sleep, vitamins and supplements and spirituality are essential to aid in a successful recovery.” - Paul Hoyer
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Ask Dr. Bennington-Davis
Dr. Maggie Bennington-Davis at the VCMHS Recovery Conference Question: Does forced treatment in the community, or outpatient committal, help or hinder recovery?
Answer: Both consumers and providers are on a journey. We are learning as we go, and hopefully we are getting better and better at engagement, partnerships, and healing. Meanwhile, we are not yet "there", and sometimes some people do still rely on external pressure and control in order to be safe, to be accepted into necessary services, and to be accepted into their families. Outpatient committal - someday - hopefully will not be necessary. When the stigma of mental illness is allayed, when providers and systems get sophisticated enough to be able to engage consumers even in the context of difficult symptoms, when society doesn't punish people for having mental illness or being in treatment, and when treatments are hardly ever harmful and are almost always helpful - then coercive measures will hardly ever be necessary. But meanwhile, the fact is that we do live in societies that are tasked with public safety and social norms outside which some behaviors are not tolerated. Some people respond to external controls in those circumstances. Not unlike jobs, clubs, and other groups with memberships, there are some things in society that one MUST do (or not do) in order to remain part of the group. Outpatient committal tries to ensure that people with mental illness know the limits of what they can and can't do. That said, not all outpatient committals are created equally. In some cases, engagement,
Page 4 partnership, hope, empowerment, selfresponsibility, and meaning can certainly occur. The outpatient committal is hardly an issue, and mostly provides a framework for funding and access. That kind of outpatient committal can certainly co-exist with Recovery. The kind of outpatient committal where one is stripped of one's rights to informed consent, or choices about medication types, to give two examples, can interfere with engagement and partnership, which in turn makes Recovery - at least in the context of treatment - more difficult. Finally, there are times when outpatient committal works and leads to symptom reduction. A good outpatient committal system will recognize when that occurs, and take advantage of the first instance when a person is less burdened by symptoms to reduce external controls. These are conversations - as most conversations are! - best continued among providers, clients, and their families. There is no "right" answer - but having the dialogue is a clear indication that you are doing the right things!
Spirituality in our System For the last 12 years, consumer based research endeavours have indicated that spirituality is important in the recovery process (Baetz & Toews, 2009; Bussema & Bussema, 2007). Yet there is a lack of clarity on how to integrate spirituality into mental health services (Clark, 2005). In order to gain direction, Vancouver Acute and Community Mental Health Services will be providing avenues for dialogue about spirituality with consumers, families of consumers, and mental health professionals in the community and hospital. We have contracted Dr. Sharon Smith to work with us to facilitate the dialogue. We welcome your participation and contribution in focus group discussions, cafĂŠ style workshops, and individual interviews. Sharon Smith can be reached for more information at sharon.smith2@vch.ca Baetz, M., & Toews, J. (2009). Clinical implications of research on religion, spirituality and mental health. The Canadian Journal of Psychiatry, 54(5), 292-301. Bussema, E. F., & Bussema, K. E. (2007). Gilead revisited: Faith and recovery. Psychiatric Rehabilitation Journal, 30(4), 301-305. Clark, N. (2005). Community mental health professionals' perspectives on incorporating spirituality in their care of clients with serious mental illness: A qualitative study. The University of British Columbia, Vancouver.
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Researching Stigma Experiences of People on Extended Leave in British Columbia By James D. Livingston Affiliations: (1) Researcher, Forensic Psychiatric Services Commission, BC Mental Health & Addiction Services, PHSA (2) PhD Candidate, School of Criminology, Simon Fraser University
Extended leave is a form of communitybased civil commitment that requires people with severe mental illness to comply with a prescribed course of mental health treatment (usually psychotropic medications) after they are discharged from hospital. It is a product of the psychiatric deinstitutionalization movement, in which the locus of mental health treatment was shifted from the hospital to the community. The general intent of extended leave is to keep people with severe mental illness out of harm’s way, out of trouble, and out of psychiatric hospitals. One question that remains about extended leave is the extent to which it positively or negatively affects the subjective experiences of people with mental illness.
Page 5 Researching ‘self stigma’ In 2006, I began a research study to examine how people with severe, persistent mental illness experience self stigma. Included in this study are a group of people who are on extended leave and are living in the Metro Vancouver area. Over a 1-year period, each person is interviewed twice about their subjective experiences with stigma. This study uses 3 different quantitative stigma measurement tools, which include more than 70 questions about stigma. Qualitative information is also obtained from each person about their perceptions and subjective experiences. Participant characteristics Thirty-nine people on extended leave participated in the study. Over half (56.4%) are males, and 61.5% identify themselves as Caucasian. On average, participants are 40 years of age. The majority (84.6%) are unemployed, and 92.3% are receiving disability benefits. Forty-one percent have less than high-school education. The majority (53.8%) have experienced homelessness in their lifetime. On average, participants have been living with mental illness for 12.2 years. Most (84.6%) are diagnosed with schizophrenia or schizoaffective disorder. More than half (51.3%) of participants have a concurrent substance use diagnosis. ‘Stigma’ in their own words
What is ‘stigma’? ‘Stigma’ refers to exclusion, rejection, blame, or devaluation resulting from actual experiences, or anticipation of adverse social judgments about people with mental illness. Self stigma refers to a process whereby people with mental illness harbor negative feelings towards themselves and their own illness.
Every interview in this study begins by asking participants to describe, in their own words, what ‘stigma’ means to them. Here are a few examples: • • •
“When people think that the mentally ill are weird or dangerous” “Someone who doesn't understand what mental illness is” “A label that destroys your whole reputation”
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Researching Stigma continued… • •
“When people treat you like a dog” “Been called derogatory names by educated professionals”
Stigma experiences The interviews reveal a wide range of stigma experiences. Almost all (95%) have experienced some form of stigma in their lifetime, with 33% reporting numerous lifetime experiences. When asked about the recent past (e.g., previous month), only 13% of participants report having numerous frequent of stigma experiences. In terms of the overall level of self stigma, only 5% of participants experience a ‘high’ level of self stigma (as quantitatively measured). The stigma measurement tools indicate that most participants (84%) have ‘minimal’ to ‘mild’ levels of self stigma. Reflections on ‘extended leave’ Participants were not asked direct questions about their experiences of being on extended leave. But, some participants did mention ‘extended leave’ in the context of stigma, including 20.5% who were vocal about the adverse effects of extended leave. Common themes mentioned by these participants include: • •
• •
feeling that their rights are being denied and freedom taken away; feeling that their life is constrained: “Extended leave puts your life on hold”; “The boundaries imposed by the extended leave has worse consequences than the illness itself”; feeling powerless: "[feels like] being a fish in a tank with cats"; feeling adverse effects from involuntary medications: “Forced to take medications that screw me up”;
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feeling different: “Been certified…makes me feel that I'm different from other people.”
Surprisingly, most of the participants didn’t mention extended leave at all, while a few people spoke about how they have benefited by being on extended leave. When asked about their level of satisfaction with their current mental health service providers (e.g., psychiatrists, case managers), 81.6% of participants on extended leave reported that they were overall satisfied, while 10.5% stated that they were dissatisfied with the services they currently receive from mental health professionals. In addition to extended leave, many participants spoke about their negative experiences with the civil commitment process and involuntary hospitalization. Participants also mentioned other interrelated factors that contributed to their stigma, such as psychiatric symptoms, medication side-effects, poverty, and unemployment. Future directions Society has deemed that civil commitment and extended leave are necessary tools for protecting the safety of the community and the welfare of some people with severe mental illness. This research suggests that there may be a small subset of people for whom civil commitment and extended leave is an extremely negative and difficult experience, with effects that are powerful and enduring. The next step is to develop strategies that aim to reduce the adverse consequences of being civil-committed and being on extended leave. More research is also needed to understand the extent to which extended leave is ‘beneficial’ for people living with mental illness and for society in general.
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PERSPECTIVES PAGES Into the Hole By Jocelyn I know I am a caring, thoughtful, intelligent, hard-working person. I am NOT mentally ill, but because of someone’s abusive actions, I had found myself certified under the BC Mental Health Act. I have been forced into the psych ward of two hospitals and have had to submit to the supervision of a mental health clinic. I am still going there, but after a very long, traumatic struggle to clear my reputation, I am now “voluntary”. Yet at the same time, I am required to go, because the doctor will not release me “in good conscience”. I am sorry to say that much of my experience has been a nightmare. Some of the doctors and nurses and social workers in the hospital were not respectful or understanding. It was as though I was a thing to be pushed around, and NOT a person who had feelings and deserved respect. So many times I was not listened to, or given any consideration. Usually there was the pre-judgment that because you have been labeled as being “mentally ill”, you are emotionally unstable, stupid, and immature. Often, natural emotions such as anger or laughter were judged to be signs of mental illness. However, in spite of my awful experiences, I can tell you some good stories too. Some of the nurses were kind to me. I wanted to watch a movie, so the nurse made me some popcorn and brought me an orange juice. At Christmas time at St. Paul’s everyone got some great gifts. I received a clock radio, a sports bag, a toque, and socks! It made the holidays very nice. We played BINGO and people got to choose a prize. At one hospital, the activities staff always have a Christmas party. I was asked to play Christmas carols on the piano and was given a giant bar of Toblerone chocolate!
Page 7 Twice, I have been given a release from the hospital, by using the Review Panel Hearing. Both times I was successful in getting out of the psych ward, but I still had to go to the Mental Health Clinic. There, I had to deal with a terrible “doctor”. I would tell him what I did that month and have a little conversation. He always wrote in the file that I was “paranoid” even though I was not. I was still very angry at what had happened to me, and all the mistreatment and abuse that I had to suffer from the police, ambulance, EMT’s, hospital psych emergency and psych wards. But NO ONE CARED. NO ONE ASKED. NO ONE LISTENED. And then I met my current doctor. She is intelligent, caring, respectful and is a good listener. But unfortunately, she is very stubborn. I also met a nurse who is respectful, caring and a good listener. I decided to release my anger, and to show my true, happy personality. I had hoped this would get me released. But it hasn’t yet, because of my doctor’s headstrong doubt. However, I am now “voluntary”, and everything is friendly. Best of all, no more horrible nightmare.
Forced Treatment? If I do not recognize that I have a problem, If I am not aware of the harm I may be inflicting upon myself, If I am neglecting my own personal care, Should treatment be forced upon me? Should I be free to make my own decisions regarding my life? I know what I want and do not want, I know what works and does not work, I know myself in ways that others do not. -Debbie Sesula
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A Mother’s Perspective on Extended Leave By Holly Horwood As a mother, I have lost track of the number of times our daughter, who is diagnosed with schizoaffective disorder, has been on “extended leave”. It could be five, maybe six times. It was first suggested to my husband and me by Vancouver’s South Mental Health Team that we lobby physicians at UBC Hospital for “extended leave” when our daughter was just 17. She is now 27, but the pattern is always the same. Hospitalization, followed by discharge on “extended leave” to a mental health team, followed by months of compulsory injections every two to four weeks, followed by more months of negotiation between her and her psychiatrist to reduce the meds, followed by a gradual – but subtle – deterioration in her condition, followed by a complete release from all medication by her psychiatrist as the Annual Review mandated by the provincial Mental Health Act approaches. This is all followed invariably a few months later with another job loss and another hospitalization when she is very, very ill. Our daughter, who can hold down a fulltime job as a legal assistant, and manage her own condominium when on “extended leave”, simply refuses – or is incapable of seeing – that she is chronically ill and needs continuous medication. She manages to do so well even on the smallest injection dose that her psychiatrist is reluctant to argue with her when she says she should be released from all medication whatsoever. Or she promises to take oral meds. A Review Panel hearing, the physician reasons, will just let her off forced medication anyway because she can
Page 8 “present” as articulate, intelligent, employed, with stable housing, family, etc. etc. etc. I am well familiar with dueling studies over forcibly medicating severely ill mental patients. Judi Chamberlin of the National Empowerment Centre in Massachusetts, points to a 1998 New York study which apparently showed little difference in outcome between a group of severely mentally ill people who received outpatient services without compulsion – including counseling for jobs, housing etc.– and a group that received services under court order. On the other hand, psychiatrist, author, researcher, and family rights advocate, E. Fuller Torrey quotes studies in which as many as 60 % of individuals with severe mental illness who had been forcibly medicated later agreed it was a good idea. Our daughter, who otherwise has a good relationship with us, remains adamant that medication destroys her brain, and we are evil for our role in dragging her into care each time we believe she is extremely ill. It’s very difficult to listen to her attacks, and each time I question whether it is worth it. As parents, we anguish over her right as a young woman to make her own decisions, particularly concerning her own health. In recent years, we have walked a perilous line between intervention – whether it be to bail her out from financial messes brought on by manic phases, or more serious matters including near starvation and paranoia so severe that she took to the streets in panic. We do intervene - simply because it is too difficult to watch our complicated, lovely, exasperating daughter sink into a maelstrom of grandiose delusions, fear and confusion that the illness wreaks on her time and time again. We believe she deserves the chance of relative “sanity” that most of us take for granted, and which medication provides. My mother, our daughter’s grandmother, who is very wise, has questioned why
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A Mother’s Perspective continued… provincial guidelines aren’t changed for patients who repeatedly come off medication and are re-hospitalized. She suggests that such patients should be restricted from legally requesting Review Panel hearings each year – instead extending the period to three, or even five, years to allow time for possible insight into their illness while on medication. I don’t know how long the cycle with our daughter will continue. At times, when she is relatively healthy on “extended leave”, our daughter refers to the fact that she “may have been sick” or that she is “getting better”. A glimmer of insight, perhaps? Discharged six weeks ago from yet another hospitalization, our daughter is now back on “extended leave”. She has a new doctor and new medication. She is back at work parttime, re-connected with her family and has a new, more positive attitude. We have our daughter back – but once again, it seems dependent on how long she remains on “extended leave”. Where we’re headed from here is anyone’s guess.
Family Members Wanted You can make a difference. The Vancouver Community Mental Health Services Family Advisory Committee (FAC) is looking for family representatives. You can be involved as a: Family Advisory Committee Member Task Group Member E-mail List member For more information, contact Shirley Rogers at: 604-708-5289 or email shirley.rogers@vch.ca
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Extended Leave: An Interview By Renea Mohammed As I walked into the Coast Resource Center to interview a fellow about his experiences of being on extended leave, I expected his thoughts on it to be negative. Extended leave is, after all, a form of forced treatment; you are required to receive treatment in the community or you are sent back to hospital. I expected this fellow to be unhappy with the force – at the apparent freedom that had been taken from him. But he expressed no dissatisfaction. He spoke positively. I’ll call this fellow Jack, to protect his anonymity, and I’ll share in this article highlights of our conversation. Jack explained to me that the term “extended leave” had not been presented to him before, but he understood he was on a “conditional release”. He understood he would be sent back to hospital if he “fouled up”. The conditions were simple: he was required to take his medication on a daily basis orally and in front of a pharmacist. His treatment team thought there had been a problem with his not taking medication. Did he find this arrangement helpful? Jack said that in the past he had had a problem transitioning to sleep. As he was falling asleep he would start to hear voices and wake up again. He said the new arrangement of taking a new medication at a higher dose in front of the pharmacist has been helpful. He is sleeping better. “How does it feel to be on extended leave?” I asked. “Not much different than before,” he answered, but he noted he sleeps better. He added that he has no concerns about his treatment. Recovery to him means having control over the voices.
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Extended Leave & Recovery? A Personal Story & Perspective By Renea Mohammed
I will always remember the fear I felt when the psychiatrist who was seeing me during my third hospitalization told me I was going to be discharged on extended leave. She told me I would be required to see a case manager, and a psychiatrist and to go for injections. It was the injections that scared me. Actually, they threw me into outright panic and I immediately rushed to the phone to call my husband in the hopes he could help me escape them. Why was I so scared? It was the fear of side effects. If I was taking pills and I had side effects the dose could be reduced or the med changed altogether. If I was injected with a long acting drug and there were side effects, all that could be done would be to add more drugs for the side effects which could, in turn, have their own side effects and might not work very well anyway. You see, I had had experience with side effects and drugs meant to control them. The first time I was hospitalized and treated by force it was absolute hell. The medication that I was made to take had side effects that were worse than the schizophrenia it was intended to treat. For three weeks I was forced to take a drug that made my thinking slow and foggy so that I had a hard time articulating how I felt, while at the same time, the drug induced akathesia. What is akathesia? I have seen it described as restlessness. I don't know what it feels like for other people, but for me it didn't feel anything like restlessness. For me it was a horrible feeling that caused me to constantly move in an effort to alleviate the feeling only it would never work. The result was that I was constantly moving. Unfortunately, I had a hard time communicating how I felt. I didn't know how to describe the feeling I was experiencing. I didn’t have a big word for it
Page 10 like “akathesia”, which was a word I learned afterward. My slow and foggy thinking didn’t help matters. As a result, I don't believe the treatment team understood how much pain I was in. For much of my hospital stay they were actually increasing the dose I was on. I was given two additional drugs for side effects. They helped a little, but did not eliminate the feeling. One of them made my eyesight blurry. I recall being told that side effects might go away in a few weeks. A "few weeks" sounded like an eternity. I wondered why they weren't changing the troublesome drug and thought it must be because all of the drugs were like that. What is my point in sharing my war stories about medication side effects? First, I want to show why the prospect of the extended leave injections scared me so much; I had had a horrible experience in the past. Second, I want to illustrate that forced treatment, if not done right, can cause pain and harm. It is all too easy to ignore the voice of the person receiving treatment when they are being treated with force. Interestingly, everything changed when I became a “voluntary” instead of “involuntary” recipient of care. When I was discharged from that first hospitalization and became a voluntary patient, I suddenly had the power to refuse to take the drug that was making me feel so awful. When I said I would no longer take it, the treatment team immediately came up with alternative drugs. This only happened when I became voluntary. It's just harder to dismiss someone's voice when they aren't being treated with force. None of the alternative drugs have had side effects as bad as that first drug I was on. There was no need for me to spend three weeks suffering. I probably sound as if I am opposed to forced treatment and its forms such as extended leave. Actually, I am not. I sit on the fence when it comes to this issue. Why?
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Because even though I had one hellish experience of treatment by force, extended leave played a huge role in my recovery process. It changed my life. The flip side to the scenario I have described is that even when drugs had minimal and tolerable side effects, I didn’t take them for long. I really didn’t believe I was ill. In my mind, there was no need for drugs because I thought the voices I heard and the delusions I had were real. A pill wasn’t going to make them go away. When I was finally placed on extended leave, I did succeed in persuading my husband to intervene. He in turn, persuaded the treatment team to base the extended leave on my taking the medication orally, under his supervision, instead of basing it on the injections that had been planned. My husband took his job of ensuring that I took my pills very seriously – even shining a flashlight in my mouth each day to check if I’d hidden the pill under my tongue. This was something I was prone to try. I was angry, furious actually, not with my husband, who I saw as saving me from the injections, but at the treatment team. As far as I was concerned, I did not have a mental illness and no one should have the right to force me to put drugs into my body. And then things changed. During my period of being on extended leave I had gradually stopped hearing voices, but had not associated it with medication. A medication change was made during this time and the voices came back. I was immediately switched back to the previous medication. This time, I had an unusually fast reaction to it. My voices stopped within a few hours of my going back on the earlier drug. The quick cessation of voices caused me to connect the medication with the voices stopping for the first time. It didn’t take weeks this time. It took a few hours. Once I
Page 11 made the connection between the drug and the voices stopping, I came to the conclusion that the medication must work. If it worked, then the voices were not real and what people had been telling me for years – that I had schizophrenia – must be true. The realization that I had a mental illness and the discovery of a drug that stopped my voices was the first big step I made in my journey of recovery. It wasn’t the whole answer. The drug didn’t replace the friends I had lost due to illness. It didn’t fill in the gaps in my resume. It didn’t rebuild my confidence. It didn’t cause me to become comfortable around people after years of paranoia. I had to do a lot of my own work to address these things and move forward in my recovery. But finding a medication that worked and learning that I had an illness was my first big step. And that first big step happened as a result of being on extended leave. I would not have been taking medication otherwise. So can extended leave play a role in recovery? I think that if it is done right, it can. It may seem to fly in the face of recovery principles such as self determination and choice. But I question whether someone is truly enjoying self determination when they refuse treatment because the illness is causing them to not know they are ill. This is very different than a person who knows they have an illness choosing to take a risk to see if they can manage without medication. The latter is a choice, the former is not. Happily, even in the former situation we don’t need to throw the principle of selfdetermination out the window. Selfdetermination can always be maximized even when there are some necessary limits by offering choice within those limits. Someone may, for example, be required to take medication, but have choice about which medications they try and stay on. Being incompetent in one area does not mean one is incompetent in all areas.
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Involuntary Treatment: A Psychiatric Nurse’s Perspective By Jennifer Glen A core ethical debate in mental health today is how to respect an individual’s authority to make autonomous decisions about their mental health even when their competence to decide this may be reduced due to mental instability. The question facing many nurses in mental health today is how to balance the client’s rights to make autonomous decisions with their need for timely treatment to attain positive outcomes for their mental health. In other words how do nurses achieve balance when what they believe the client’s needs conflicts with the client’s beliefs about what is in their best interests (Trinh et al., 2008). One criticism of involuntary treatment is that it is seen as to be violation of individual human rights. How then does one minimize intrusions on a client’s autonomy without violating their personal integrity or personhood? Johansson and Lundman (2002) suggest that despite being involuntarily admitted, the individual can still be presented with choices. They have the right to be given information about their treatment options and to be included in the decision-making process in terms of treatment plans. Building rapport with the individual and identifying their perceptions, while carefully explaining to them the benefits and risks of treatment, can help guide ethically sound treatment, as the nurse will have more understanding of who the client is as a person (Trinh et al., 2008). Nurses have an ethical and moral obligation to enhance client autonomy by advocating for their clients and encouraging selfdetermination with the goal of restoring autonomy (Valimaki & Leino- Kilpi, 1997). Engaging with the client in this matter requires a therapeutic relationship based on mutual respect and caring. According to
Page 12 medical ethics, when a client has been established as having a diminished capacity for autonomy, committal is not seen as interfering with their rights as a rational agent. Social paternalism, as described by McLachlam and Mulder (1999), is the hospitalization of an individual for the protection of the public rather than the benefit of the patient. They argue that social paternalism is not acceptable. This is supported by British Columbia’s Mental Health Act, where the clients risk to themselves or others is only one of four criteria that must be met for involuntary treatment. Rationalizing care based on the concept of paternalism is criticized by opponents of involuntary treatment. However, in the medical field it has been widely accepted that paternalism can be ethically justified based on the idea of beneficence, that is, when the care giver is providing involuntary treatment for the good of the client (O’Brien & Golding, 2003). There are two ethical justifications for paternalistic actions; beneficence and nonmalfeasance. There can be a fine line, ethically speaking, between medical paternalism and acting coercively with a mental health client. It’s clear that deeming an individual incompetent to make choices about their mental health can be damaging in many aspects. The debate here is weighing this potential harm with the benefits of receiving timely and appropriate intervention to minimize overall harm. The underlying question here remains, is this form of treatment justified? Involuntary treatment in psychiatry remains an ethically contentious issue. Ethical concerns about infringing on a client’s human rights are generally countered by the argument that the treatments lead to beneficial outcomes. On the other hand, empirical research has yet to demonstrate statistically significant
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A Psychiatric Nurse’s Perspective continued… outcomes showing that compulsory treatment has an impact on overall outcomes in terms of client functioning or long term illness reduction (Sheehan, 2009). Involuntary treatment is one ethical dilemma all Psychiatric Nurses will encounter. In British Columbia our mental health and legal systems support this intervention based on beneficence. Being aware of the effects, both positive and negative, that this intervention has on our clients is essential for nurses to consider due to the impact it will have on our relationship with our clients. Documents such as the Code of Ethics for Nursing and the Psychiatric Nursing Standards of Practice provide clinical guidance to nurses and support them in making ethically sound decisions (Yeo & Moorhouse, 2005). Selfreflection can be an important step missed by many nurses as we get caught up in our day to day busy practice. Reflection can emphasize the importance of the nurse-client relationship. Establishing a caring and trusting relationship can minimize the negative impacts of involuntary treatment, and will encourage nurses to maintain as much of the individual’s decision making abilities and autonomy as possible, despite their involuntary status. This discussion has not, however, convinced me that involuntary treatment is unethical. Each situation must be evaluated independently, weighing the benefits and potential harmful outcomes of such intervention. It’s very possible that this intervention is overused; however, it is clear to this writer that there are times when involuntary committal is necessary for the protection of the individual. That being said, the impact this decision has on the individual can be damaging. Psychiatric
Page 13 Nurses can minimize this negative impact by using their therapeutic self and being upfront, honest, transparent, kind and considerate to our clients during this scary transition. With such support, this form of intervention has the possibility of being perceived by the individual, in the long term, as positive and beneficial. References British Columbia: Ministry of Health. (2005). Guide to the mental health act. British Columbia, Canada: Library and Archives Canada Cataloguing in Publication Data. http://www.health.gov.bc.ca/library/publications/ year/2005/MentalHealthGuide.pdf Heffern, W., & Austin, W. (1999). Compulsory community treatment: ethical considerations. Journal of Psychiatric and Mental Health Nursing, 6, 37-42. Johansson, I.M, & Lundman, B. (2002). Patients’ experience of involuntary psychiatric care: good opportunities and great losses. Journal of Psychiatric Mental Health Nursing, 9, 639-647. Kitamura, T., & Takahashi, N. (2007). Ethical and conceptual aspects of capacity assessments in psychiatry. Current Opinion in Psychiatry, 20, 578-581. McLachlan, A.J., Mulder, R.T. (1999). Criteria for involuntary hospitalization. Australian and New Zealand Journal of Psychiatry, 33, 729-733. O’Brien, A, J., & Golding, C.G. (2003). Coercion in mental health care: the principle of least coercive care. Journal of Psychiatric and Mental Health Nursing, 10, 167-173. Olofsson, B., & Norberg. A. (2000). Experiences of coercion in psychiatric care as narrated by patients, nurses and physicians. Journal of Advanced Nursing, 33(1), 89-97. Salize, J.M, & Dressing, H. (2005). Coercion, involuntary treatment and quality of mental health care; is there any link? Current Opinion in Psychiatry, 18, 567-584. Sheehan, K.A. (2009). Compulsory treatment in psychiatry. Current Opinion in Psychiatry, 22, 582-586. Torbec, I, & Herbst, M., & Zvanut, B. (2009). Differentiating between rights-based and relational ethical approaches. Nursing Ethics, 16(3), 283-291. Trinh, N., & Moore, D., & Brendel, D. (2008). Ethics consultation to PACT teams: balancing client autonomy and clinical necessity. Harv Rev Psychiatry, November-December, 265-372. Valimaki, M., & Leino-Kilpi H. (1998). Preconditions for and consequences of self-determination: the psychiatric patient’s point of view. Journal of Advanced Nursing, 27, 204-212. Yeo, M., & Moorhouse, A. (2005). Concepts and cases in psychiatric nursing (2nd ed). Peterborough, Ontario: Broadview Press
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To Be Honest By DKYP
To be honest, extended leave was not on the top of my priority list at the time I was put on it. In fact, I paid little attention to it. I followed it, went to the doctor’s office for my depo, went regularly to see the psychiatrist, or went to the Day Program because I had to. I didn’t need to work because I was financially supported by the system and by my parents, so I had the time for these things. But I felt desperately in need of financial independence and social independence. I had been horrifyingly robbed of my freedom, locked in the psych ward and also robbed by illness of mental capabilities that would have allowed me to have a sense of time or to remember important things that most people take for granted like “where did I put my wallet?” I wanted to be self-housed, to have a career, to be competent again in every way. These felt like my top priorities - not the rehab program. Full self-reliance was what I wanted. I wanted to find a job. That was my priority. But really, I needed to be well again before I could pursue those things. Contradictory? Of course it was. Despite the advice of the psychiatrist, I went about looking for work that I could do with my then vegetable brain. My happy goal to become a psychologist in high school became drawing portraits for people in Stanley Park. When I realized my cognitive deficits left me drawing ugly happy faces, my goal became to be a dishwasher at Ebi, the Japanese restaurant. When I applied there with my resume, the staff said, “What? Don’t you want to be a waitress?”. “No, a dishwasher.”
Page 14 But I refused to believe I needed to be dependent on someone or some system forever. But I refused to believe I needed to be dependent on someone or some system forever. I refused to be on disability income. It would ruin my karma, I thought. The official status of being a mentally disabled person felt like having words written across my forehead such as: “Gullible” or “Receiving free money because I am lazy,” or “Incapable person - need reliance forever”. I thought it would attract scammers and criminals so that I would be taken advantage of. I needed to find work! But the doctors ordered extended leave. It didn’t make sense to look for work and financial independence when getting better and healing my veggie brain first was what I needed to do. Realistically, extended leave does not only mean the regular doctor’s visit and rehab program. But it should be a symbol to signal recovery action mode. That means for me, a healthy sleep schedule, a well-rounded diet, exercise, and not letting my brain deteriorate to apple sauce. I also tried hard to read again and do puzzles. I think this should be kept up until mental clarity, accuracy, and precision is fully functional again. The difference between extended leave and an involuntary hospital stay is that extended leave forcefully braces an individual to their medical assessment and medications, but with the important realization of the freedom to demonstrate one’s own will to do what one perceives as recovery action mode. What concerns me is that every individual’s recovery action mode is different. It is an individual’s perception of one’s world circumstances driven by an emotion of internalized fear and vulnerability as a patient. I thought my recovery action mode was finding work first , so as to be self-reliant, but it was really about getting health back before finding work. I followed the doctor’s orders because I trusted the doctor enough to know his intention was to get me well again. That was fortunate: I wasn’t paranoid of doctors. I imagine that I could have lost the last grasp of reality and prioritized saving the world from war and natural disasters and acted upon it.
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To be Honest continued… Because why would John Nash adhere to taking in pills to bog down his glorious strategic mathematical brain from saving the world? Not that we don’t need saving from such things, but was my veggie brain aware that there are professionals who keep these things in gear already? Now I have graduated from veggie brain to chicken brain. I don’t feel vegetative enough to withdraw from social contact, work and education. Now I feel chicken about my brain. I fear its vulnerability and susceptibility to stress, irregular sleeping patterns, and bad diet. I use help lines when I am paranoid and hang out with friends when I am sad. I tell my case manager everything. I have graduated from recovery action mode and am back at “Foundations 101 - Making a Balanced Life” mode. What I haven’t graduated from is my Bachelor of Arts in Psychology. I am taking two courses at a time, participating in water sports, running when I remember to, and drawing portraits for patients. Life can be better as long as I keep on trying.
On other topics… An Neurolinguistic Programming (NLP) Model of Microaggressions in Mental Health By Andrew Moreno Doctors have long been sensitive to their bedside manner when treating patients. They know that how they act towards their patients greatly influences their patients’ ability to recover from the illness being treated. At the VCMHS Recovery Conference, several of the panel members mentioned the need for being aware of microaggressions when treating mental health clients. Microaggressions are basically the result of health care professionals not being aware of their "bedside manner". Neurolinguistic Programming has a linguistic tool called the Meta Model that can be used to classify microagressions. Neurolinguistic Programming, developed by Richard Bandler (http://www.richardbandler.com) includes a
Page 15 Meta Model which can be used to classify various types of spoken or linguistic microaggressions. There are 3 main types of linguistic patterns in this model: distortions, generalizations, and deletions. In addition NLP contains a model based on neurological levels: spirituality, identity, role, values, capability, behavior, and environment that can be used to classify spoken microaggressions in the distortions category. Distortions An example of a spoken microaggression in the distortions category would be a spoken presupposition or implied presupposition such as "Even when you are older, your mental illness will still be present". This distortion contains a presupposition that the patient will not recover. Generalizations An example of a spoken microaggression in the generalizations category would be the use of the words "always" or "never" such as "You will never recover from your mental illness" or "You will always have to seek treatment from a mental health team". Another example of a spoken microaggression in the generalizations category would be the use of the words "can't" or conditional can statements such as "You can't get a good job because you have a mental illness" or "You can't get a good education because you have a mental illness" or "You can only go places that other clients or consumers go". Deletions An example of a spoken microaggression in the deletions category would be the failure of a doctor to mentioning the side effects of medication prescribed to mental health consumers. Conclusion Awareness of these microaggressions can help health professionals increase the quality of care given to mental health consumers by limiting their use of these distortions, generalizations, or deletions, and instead using verbal communications that contribute to their patient’s recovery. Andrew Moreno is a consumer and a Certified Neurolinguistic Programming Practitioner.
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Healing Touch for Mental Health By Laura Haskell Healing Touch is a relaxing, nurturing energy therapy. Gentle touch assists in balancing your physical, mental, emotional, and spiritual wellbeing. Healing Touch works with your energy field to support your natural ability to heal. It is safe for all ages and works in harmony with standard medical care. Anxiety and depression are very common in today’s global society. The effects of these disorders can create personal, family, and community hardship. Healing Touch may be able to help alleviate some of that suffering. Depression is a complex disorder that often times requires medical treatment. In one study symptoms of depression using a standard test were found to decrease faster with those receiving Healing Touch.(1) In an Australian study(2) depression was found to result in a disconnection from self, others and the world. Healing Touch was helpful in providing an opportunity for the patients in this study to experience understanding, safety, trust and positive anticipation in order to reconnect with the self, others and the world. When I was first introduced to Healing Touch, I was a hospice volunteer for Burnaby Hospice Society and I was approached by the cocoordinator offering to pay for me to take a course in Healing Touch. I was aware that some of the other volunteers took the course and that they were giving it to palliative care patients . I took the course and I liked it very much so that I pursued it further. Presently I have my 3rd level in Healing Touch through The Healing Touch Program. (taught at Langara College). One of the things I realized about Healing Touch is that it can be used not only to help palliative care patients, but also to help people with mental health concerns such as depression, anxiety, post-traumatic stress disorder, addiction, etc., etc. In addition, there has also been some research done using Healing Touch on people recovering from psychosis. Healing Touch has helped me a great deal in dealing with stress. There have been many occasions where I’ve cried throughout the entire
Page 16 session and after the session was finished, I felt so much grief, anger, stress, etc. had been lifted away from my soul. Another experience I had with Healing Touch is I saw white light – it was crystal-like white light and this was so profound for me. I did some research about this white light and I found out that it was the “divine,” my “higher self” that I was experiencing. On another occasion, when I was receiving the heart charka realignment technique, my spirit actually went to a beautiful place of calmness, peace, and serenity. Now, this was definitely profound for me since I have so much anxiety that not even hypnotism was successful in doing this for me. Healing Touch has also been a spiritual experience for me. It’s given me a feeling of peace, freedom, serenity, hope, connected to earth energy or others, grounded and reflective. Today, Healing Touch has become a part of my life just like eating and sleeping. 1. 2.
Leb, C. (1999). The Effects of Healing Touch on Depression Healing Touch Newsletter, 8(3), p. 2. Van Aken, R. (2004). The experiential process of Healing Touch for people with moderate depression. Doctoral Dissertation. School of Nursing and Health Care Practices, Southern Cross University, Australia.
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Credits Renea Mohammed, Editor Contributing Writers: Dr. Maggie Bennington-Davis, Simon Davis, DKYP, Jennifer Glen, Laura Haskell, Holly Horwood, Paul Hoyer, Jocelyn, James D. Livingston, Renea Mohammed, Andrew Moreno, Wendy Porter and Anita Smith.