Indonesians with Mental Illness Placed in Cages, Chained

An estimated 30,000 Indonesians with mental illness are placed in cages and chained because of stigma and lack of access to treatment. Last year, the government’s department of mental health announced “Meuju Bebas Pasung,” a roadmap to free people in chains. Although officials have worked to reach communities and raise awareness, the task is difficult because mental health remains low on the government’s list of priorities. (Globalpost, 9/12/11)

Reposted at darkestcloset.bloggerspot.com

Ethical Concerns in Assertiveness Community Treatment

Author Daniel Farrell is cited in an article featured on the Homelesssness Website and newsletter, in a discussion of ethical concerns about Assertiveness Community Treatment (ACT)

http://homeless.samhsa.gov/Resource/View.aspx?id=52119
Reposted at darkestcloset.bloggerspot

Description: Some critics call Assertive Community Treatment (ACT) a fundamentally coercive model of care because of the level of control that case managers have over their clients’ lives. This article explores some of the resulting ethical concerns of using the ACT model. This article is the third in a series of three articles about ACT.

Embedded in Assertive Community Treatment (ACT) is the element of, well, assertion on the part of service providers. This has led some critics to call ACT a fundamentally coercive model of care. And indeed, many ACT providers find the balance between social control and client independence a very difficult one to strike.

Social Control versus Client Independence

Traditionally, mental health treatment has focused on acting in the best interest of the client. ACT, however, has been accused of being more concerned with benefits to systems instead of individuals. ACT’s community-based approach has its roots in inpatient psychiatric care. Because of this, the idea of patient independence or freedom has been very limited from its earliest beginnings.

These roots can be seen in various forms of social control that are still present in ACT. For instance, ACT staff has the power to force clients into hospitalization, or to remove them from a homeless shelter or drop-in center. They may also demand that clients change their behavior, forcing them to take medication or abstain from alcohol, for instance. If clients do not comply, they may face loss of personal freedom.

ACT staff may also control many other aspects of clients’ lives. They may manage flow of money for clients, their access to doctors and pharmacies, decisions about treatments, and contact with their social networks. The ongoing ethical challenge for ACT staff is to strike a balance. They need to empower clients without neglecting them, care for them without controlling them too much, and give them as much independence as possible even while intervening in their lives.

ACT: A Coercive Model?

It is easy to see how some would perceive coercion to be woven into all aspects of ACT. And it is true that this can happen in many ways. However, some ACT clients are at the extreme end of psychosis. They may suffer a great deal because of their untreated symptoms. Moreover, their experiences may render them unable to understand their illness and their right to humane treatment. In such cases, compassionate coercion may be what allows ACT staff to fulfill their client’s right to this treatment.

It may be helpful to think of coercion on a continuum. At one end is friendly persuasion, in the middle is control of resources, and at the other end of the spectrum is the use of force in treatment. The level of involvement from the case worker depends on many factors, most especially the severity of the case.

What do the critics think?

There are many different players involved in Assertive Community Treatment. Of course, the main players are the clients themselves and their teams of providers, but there is also a diverse community of people who are interested in treatment outcomes.

ACT clients are largely lower-income, rely on public assistance, and have historically had minimal input into their own treatment to begin with. Critics of ACT say treatment that is forced upon individuals is inherently coercive (especially individuals with limited options, as described above). They see this as especially true because a person enrolled in ACT cannot end these services.

Criticism of ACT goes beyond the question of coercion, though. Some doubt the positive outcomes for ACT clients. They argue that the results seen with ACT are not actually all that different from standard treatment, and concerns about the design of studies comparing the two have also been raised.

In addition, critics say that the greatest benefit of ACT (reduced hospitalizations for clients) is not a result of the intervention itself. They see this as simply a part of the design of the model, and administrative distinctions which seek to move clients away from hospitals in general.

What do clients think?

In some ways, it is not surprising that clients themselves did not have a voice in the debate surrounding ACT until decades after the model was developed. But in the mid-1990s, the academic community did start asking clients about their experiences with the program.

Some studies looked at the most important factors in client satisfaction. They found that for clients, these included having consistent contact with staff, supportive services, a positive helping alliance, and a sense of trust and caring by ACT staff. Other studies found that clients enrolled in ACT were happy with housing assistance and the help they received in adjusting to their communities.

The feedback wasn’t all positive, though. One study found that even though clients were satisfied with many aspects of care, they were not happy with medication and treatment issues. Clients in another study said they disliked what they saw as “program intrusiveness.” They felt that the program was too confining and echoed earlier sentiments that there was too much of a focus on medication compliance.

In the end, the question of coercion in ACT may be largely a matter of opinion. But what is less subjective is the issue of balance, as service providers are pulled between control over and independence for their clients.

Read the first two articles in the series: All About Assertive Community Treatment (ACT),  Assertive Community Treatment (ACT) for People Experiencing Homelessness

 

 

Minds On the Edge

This is a video of a discussion on treatment of mental illness. It is created from two hypothetical situations of individuals who experience severe mental illness. It also features Dr. Fred Friese.
http://www.mindsontheedge.com/watch/

Reposted at darkestcloset.blogspot.com

FDA panel advises more testing of 'shock-therapy' devices

By David Brown Washington Post Staff Writer Friday, January 28, 2011; 10:10 PM

An expert panel advising the Food and Drug Administration decided Friday that electroconvulsive therapy (ECT) machines should undergo the same rigorous testing as new medical devices coming onto the market - a decision that could drastically affect the future of psychiatry's most controversial treatment.

The majority of the 18-member committee said not enough is known about ECT, also known as "electroshock" or simply "shock" therapy, to allow the devices to be used without more research into its usefulness and hazards.

If the agency follows the panel's advice, which it usually does, the two companies whose machines are used in the United States will have to provide evidence of the therapy's safety and effectiveness either from existing research or new studies. If the FDA isn't convinced, the devices could be removed from use.

The panel's opinion is the latest chapter in ECT's seven-decade history, during which the treatment has been lauded as a lifesaver, villified as a form of legally sanctioned torture, and has seen its popularity rise in recent years after a long decline.

ECT machines deliver an electrical current to the brain, inducing a generalized seizure in which the patient briefly loses consciousness. How that may be therapeutic or cause permanent memory loss - the side effect most frequently mentioned by patients - isn't known.

About 100,000 Americans undergo ECT each year, usually getting about a dozen treatments over several weeks. Some then get "maintenance" ECT every few weeks, as the therapeutic effect, when it occurs, often doesn't last. The treatment is most often used for depression and has also been prescribed to patients with schizophrenia, catatonia, and more recently, to some violent children with autism.

"It was the best possible outcome we could have gotten," said John Breeding, 58, a clinical psychologist from Austin who says the procedure should be banned. He testified before the panel at a two-day meeting in Gaithersburg.

For some patients, ECT epitomizes what they view as the coercion and lack of respect for the patient's point of view that is unique to psychiatry. That's also largely how it's been depicted in popular culture, most famously in the book and film "One Flew Over the Cuckoo's Nest," where it was a tool of punishment and social control of mental patients.

"I lost not only my memories of the time I was subjected to this torture but I was robbed of almost all memories from about 2003, two years before treatment, to 2008, three years after treatment stopped," testified Evelyn Scogin, a special-ed teacher who got ECT after a suicide attempt. Her statement was read by a friend because Thursday's snowstorm stranded her in the Charlotte airport.

Other patients described ECT as a lifesaving, if mysterious, treatment worthy of wider use.

Among them was Kitty Dukakis, the 74-year-old wife of 1988 Democratic presidential nominee and former Massachusetts governor Michael Dukakis. She first got ECT at age 63, and continues to get it once a month.

"It is not an exaggeration to say that I don't think I would be alive without ECT. It has been a miracle in my life," she said.

One proponent, a nurse from Baltimore, drove through the snow on her day off to read a grateful Christmas card from a patient, choking up as she did.

"I actually think it's more controversial than abortion," Amy Lutz, a 40-year-old mother of five from Villanova, Pa., said of ECT, which her 12-year-old autistic and manic-depressive son gets regularly.

She brought with her two poster-size photographs of the boy, his face and hands bloodied from self-inflicted blows. She told the committee that ECT, tried after a half-dozen other therapies, stopped the violent behavior and increased her son's achievement in school.

A 1976 law requiring safety and effectiveness of all new medical devices permitted ones in longstanding use, including ECT machines, to stay on the market. Later, however, Congress told the FDA that those grandfathered-in devices either had to undergo rigorous testing or be officially "reclassified" as already-proven to be safe and effective (although, in some cases with special warnings about their use).

In addition to patient testimony, the advisory panel heard FDA staffers describe their analysis of hundreds of ECT studies.

As a group, the studies tended to be poorly designed and with too few patients to allow the drawing of firm conclusions. Many failed to follow patients long enough to discover the duration of ill effects. Ones done decades ago studied techniques and electricity dosages different from current practice.

The FDA staff reported the existing research suggests that for depression, ECT is more effective than placebo or "sham" shocks and after a month more effective than antidepressants.

In terms of hazards, the FDA staff's review found the treatment is associated with "impairment in orientation, memory and global cognitive function immediately after ECT and up to 6 months." Certain aspects of memory may return to baseline after six months. "Autobiographical memory" - recollection of events in one's life - appears to be at greatest risk. High-dose electric current and current applied to both sides of the brain are associated with more thinking and memory problems.

Panel member Christopher A. Ross, a psychiatrist and neuroscientist at Johns Hopkins University, asked if the published studies identified any risk factors that predisposed patients to memory loss and thinking impairment.

"Evidence-based data for that issue just doesn't exist," said Peter G. Como, a neuropsychologist at the FDA.

Panel Chairman Thomas G. Brott, a neurologist at the Mayo Clinic's campus in Jacksonville, Fla., said he was amazed that essentially no research had been done on ECT's effects using functional MRI imaging, repeated brain wave (EEG) studies, or autopsy examinations of patients.

"I tried to look and saw very little. I concluded that the evidence is not there to decide either way," he said.

Recent "State of the Union" with DR. Fred Frese

Frederick J. Frese, Ph.D., Associate Professor of Psychiatry, Northeastern Ohio Universities College of Medicine, and RTP Steering Committee Member, was featured on CNN’s “State of the Union,” discussing the mental health aspects of the Arizona shootings.

To watch the video clip, please visit:

http://www.cnn.com/video/data/2.0/video/politics/2011/01/16/sotu.01.16.frese.earley.cnn.html