Assisted Treatment

Assisted treatment is a euphemism for obtaining the legal means to ensure that an ill person receives medical care even if he otherwise refuses it. This subject presents a dilemma. Every person has the right to make important decisions, such as whether or not to take medicine with potentially serious side effects. On the other hand, what is to be done if the very illness a person suffers from prevents him from seeking treatment? A would-be caretaker could actually be negligent if she did not insist on treatment under those circumstances.

Essential

According to U.S. law, the potential benefit of treatment on the patient overrides her objections to it if the disease in question prevents her from using logical, rational thought to make her decision concerning medical care. Schizophrenia is one such condition that distorts patients' thinking processes.

As a caregiver, you can assure that a patient receives treatment by becoming his guardian or conservator. You may also seek to have the patient committed either as an outpatient or to a psychiatric in-patient hospital. Outpatient commitment laws vary from state to state. The Treatment Advocacy Center in Arlington, Virginia (www.treatmentadvocacycenter.org), provides excellent background information on the topic of assisted treatment. It is the source of much of the information in this section.

Advance Directives

In some states, a patient who is free of symptoms of schizophrenia may be able to sign a legal document directing others how he wishes to be treated if he relapses. This document may spell out who can direct his care and what kind of assisted treatment he expects, if any.

The Treatment Advocacy Center points out that there are potential problems with this option. First, it is not clear how well it works in practice. Second, patients have no way of knowing whether new symptoms of schizophrenia or another mental illness will be present if they relapse. Deciding on treatment options in advance can be counterproductive because they may not adequately anticipate future needs in the event of a relapse.

Question

What is a Ulysses contract?

It's another name for an advance directive. Ulysses is the hero of Homer's epic poem “The Odyssey.” Ulysses sailed close to the isle of the seductive Sirens, who lured sailors to their deaths. Ulysses had his men plug their ears but had himself tied to the mast of his ship so he could hear the Sirens' call. He instructed his men not to untie him, no matter what he said, until they were past the threat.

If you are interested in pursuing an advance directive, you will first need to find out if your state recognizes them. Then you will need to consult both a lawyer and psychiatrist.

Assertive Case Management

Assertive case management programs track down patients and bring treatment to them. The National Alliance on Mental Illness (NAMI) is dedicated to promoting these programs, also known as assertive community treatment (ACT) and program of assertive community treatment (PACT) services. These programs even help those whose illnesses prevent them from showing up for treatment at traditional mental health care facilities.

Unlike agencies that direct patients to mental health care treatment centers and services, successful delivery of care under these programs does not depend on the discipline of the patient, whose illness may hinder medical compliance. This results in a better level of care for the patient.

Fact

NAMI uses PACT and ACT interchangeably to refer to assertive case management programs.

Several studies have found that ACT teams, which are composed of doctors, nurses, therapists, and other professionals, significantly reduce rehospitalization days. In one study of homeless individuals, the reduction was greater than 50 percent. During the following year, those treated by the ACT team also spent less time in the hospital, living on the streets, and locked up in jail. The ACT patients received more medical treatment overall than those in outpatient care. Nevertheless, at any given time, one in three were not taking their medicine, a finding that led the Treatment Advocacy Center to conclude that ACTs are a valuable tool but are not effective for all patients.

This might be expected for homeless people suffering from schizophrenia since they are more difficult to treat than are patients living with their families, in their own homes, or in group residences. For these patients, ACTs bring well-documented advantages over less consumer-friendly treatment scenarios, including involuntary outpatient care.

Representative Payee

It is possible to have a patient's social security insurance, disability insurance, or veteran's administration payments sent to a family member, a mental health care facility, a clinic, or a case manager if the patient is unable to handle his own financial affairs. The person who takes responsibility for the patient's finances is called a representative payee.

This practice has been shown to have several benefits, including reduced rates of hospitalizations, homelessness, and substance abuse. There have not been any long-term studies to track the efficiency of this method, but the center suggests it may be useful to make the patient's access to the monthly payments contingent upon maintaining a treatment plan.

Conditional Release

A court can order the release of someone committed to a psychiatric hospital and impose conditions on the patient. For example, the patient may be allowed to receive treatment outside the hospital so long as he takes his medication and attends therapy sessions. If he stops treatment, he can be rehospitalized. The majority of states have laws allowing conditional release. It is up to the hospital director to determine whether the patient should be treated in or out of the hospital.

Although conditional release is commonly used for patients who have committed crimes, it sometimes is employed for others. The Treatment Advocacy Center cites data showing that in the state of New Hampshire, 27 percent of non-criminal patients committed to hospitals were released conditionally in 1998. A follow-up study of twenty-six seriously ill psychiatric patients in that state showed impressive improvements in medical compliance after one and two years on conditional release compared to the year before hospitalization.

Mandated Community Treatment

This type of outpatient commitment differs from conditional release in that it involves a court ordering a patient to receive treatment outside the hospital if he wishes to reside in the community. Failure to comply can result in rehospitalization. Mandated commitment helps people living with schizophrenia get better care by increasing the chances they will stick to their treatment plans.

Essential

Mandated community treatment is also called outpatient commitment, assisted outpatient treatment, or involuntary outpatient commitment. It is a form of assisted treatment in which a court orders someone with a serious mental disease such as schizophrenia to obtain treatment without being committed to a hospital or other institution.

Most states have laws that allow their courts to order patients to receive outpatient care. Check with your mental health care provider or lawyer to find out if this a good option for your situation.

The Treatment Advocacy Center refers to several studies supporting the value of court-ordered community treatment. In one, 60 percent of patients ordered into treatment programs agreed, after receiving treatment, that it was a good idea.

A separate study conducted in New York by the New York State Psychiatric Institute and Columbia University found that initially about 50 percent of those ordered to accept treatment were embarrassed or angered by it. But the study found the following results after treatment:

  • 75 percent attributed a gain in their ability to better control their lives to the enforced treatment

  • 81 percent credited mandated treatment with helping them “to get and stay well

  • 90 percent said the experience increased the chances they would accept treatment, including taking medications and keeping appointments

  • 87 percent were confident their case manager could help them

  • 88 percent agreed on their therapeutic priorities

  • Studies in at least half a dozen states indicate that mandated outpatient treatment improves lives. Multiple studies document significantly reduced cases of homelessness, psychiatric hospitalization, and trouble with the law among patients ordered to undergo outpatient treatment.

    Fact

    More than one assisted treatment approach can, and in many cases should, be applied to a patient, depending on her needs. An assertive case management program, for example, can be combined with a guardianship, appointment of an assertive case manager, and/or a representative payee.

    Conservatorship

    A person appointed by a court to make decisions for someone who has been judged mentally incompetent is called a conservator or guardian. Conservatorships and guardianships are commonly established in cases of mental retardation or dementia, but they can also be useful for patients with mental illnesses. A California study of the effectiveness of conservatorships in California found that mental health consumers who had conservators had significantly longer periods of mental health stability.

    Benevolent Coercion

    Benevolent coercion is a euphemism for a well-meant threat. Basically, a patient who won't submit to treatment is told he will be committed unless he accepts treatment. The Treatment Advocacy Center estimates that this approach is used but is generally not discussed.

    It is difficult to assess the effectiveness of this approach because it is an informal practice with no regulation. It might be used by caregivers, family members, judges, or anyone who has the potential to influence the care and treatment of a person with schizophrenia. It would not be surprising, however, if its effectiveness depended on the individual patient's history, medical condition, and ability to exert self-control.

    Treatment or Jail

    In some communities, informal arrangements may be agreed upon between local authorities and mental health care providers according to TAC. The police arrest seriously ill patients on minor charges if they refuse to accept treatment and pose a safety risk. A judge then suspends their sentences as long as they return to treatment. The problem with this approach is that the judge's only option is to jail the patient if he continues to avoid or refuse treatment. Psychiatric care in jail is often minimal if it is available at all.

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