Involuntary Treatment Meeting Summary

Appendices:
II. Recommendations from "Reports of Three Roundtable
Discussions on Involuntary Interventions," by Andrea Blanch
and Jacqueline Parrish, 1993

Recommendations

The group also generated a series of recommendations directed at the various levels of the system: federal, state, local, and individual.

Federal Level

Recommendations for the federal level were in the areas of national leadership, follow-up meetings, technical assistance/training, and research.

In the area of national leadership, follow-up meetings that Center for Mental Health Services consider:

Implementing specific initiatives to address the issues of involuntary interventions.
Including these issues in discussions of health care reform.
Convening a meeting to articulate an alternative vision of managed care in the public mental health system, based on learnings from previous system change efforts, and incorporating the principles discussed in this meeting. A model could be developed that 1) is based on the substantial experience of public mental health systems in managing the overall care of persons diagnosed with severe mental illness; 2) translates the concept of a Asingle point of responsibility@ into managed competition and a range of choices for consumers rather than coercion; 3) adequately incorporates solutions which show a long-range return on investment; and 4) prevents the diversion of individuals who are more difficult and costly to treat into other sectors, such as the criminal justice system.
Amending the comprehensive mental health planning process to require states to consider options to decrease the need to use involuntary interventions.

In the area of follow-up meetings and contact, participants recommended that consider:

Convening a follow-up meeting of a diverse group to formulate strategies to address the issues identified in the series of meetings.
Convening a meeting to define how clinical training should be restructured to reflect these issues.

In the area of technical assistance and training, participants recommended that CMHS consider:

Developing and disseminating best practice standards in areas such as the use of seclusion/restraint.
Convening a national conference, similar to a CSP Learning Community Conference, focused on this issue.
Identifying model programs and best practices where minimal involuntary care is used, and where individuals are not being diverted to the jails and prison.
Funding clinical training grants that incorporate consumer input and focus on the skills necessary to use community programs and non-coercive options (also, restructure the obligations of grants recipients)
Having staff make presentations about the three Roundtable discussions at various meetings and conferences.

In the area of research, participants recommended that the CMHS continue, and to the extent possible, consider expanding the following activities.

Funding research and demonstrations to examine the efficacy of different options (including consumer-run programs, holistic approaches) and systematic approaches to changing practices.
Highlighting the heterogeneity of the population in all research and demonstration programs.
Supporting research on how to help people who will not use mental health services voluntarily and whose failures lead to the visible community problems of homelessness and violence.
Funding consumer preference surveys and consumer satisfaction studies on the use of involuntary interventions and crisis alternatives.

State and Local Levels

Participants offered the following recommendations for state and local mental health agencies and organizations:

Mental health systems should examine how they contribute to the problems and how they could stimulate changes that do not require major legislative reform. For example, the system in the District of Columbia is committing about half as many people as it was 10 years ago, because clinicians are better able to intervene early before the individual reaches the emergency room.
The National Association of State Mental Health Program Directors should consider developing a position paper on this topic.
States should consider redirecting financing to encourage the development of 1) non-coercive options; 2) continuous, community-based systems of care; and 3) peer support programs.
States should develop procedural agreements between mental health and law enforcement agencies and provide training on how to implement these agreements. CMHS should develop basic standards to guide states in this process, based on the discussions in this meeting.
Programs should arrange for the parties of interest to sit down at the same table to discuss the issues from their perspectives. The process of doing this could improve care, diffuse anger, and increase empowerment particularly in inpatient settings.
States and localities should organize a program for groups of consumers to provide values-based training for staff and to sensitized clinicians to the impact on the individual of the use of involuntary interventions.
Staff need to be trained on how to talk to the healthy parts of the person which are present in even the most disabled persons. Promoting such humane environments may engender a less violent atmosphere.
Consumer/survivors should be full participants in all quality assurance, training, consciousness-raising, and policy and program development.

Conclusion

The topic of involuntary treatment has long been both controversial and polarizing. People have often felt that the differences between groups on this issue were too great, and the options too few, for change to be possible. However, the roundtable discussion process has demonstrated that the major stakeholders in fact have much in common. Despite substantive differences expressed during the three meetings, there were many areas in which agreements were reached. Most importantly, all participants agreed that the current system of involuntary treatment is not working well for some individuals in some places, and that overall use of involuntary treatment in the system can and should be reduced.

The roundtable discussion process also made it clear that involuntarism within the mental health system is not solely a legal issue, but includes clinical, programmatic, and organizational aspects. Many significant improvements appear to be possible even without statutory change.

The group expressed the belief that making changes in this area will require concerted and persistent attention. Many of the principles and recommendations developed during this process provide significant challenges to current practice. Structural, political, and financial barriers will undoubtedly impede progress. Nonetheless, the group agreed that a mental health system which reflected these discussions would be more responsive and ultimately more effective for all parties.