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

 

 

I Would File this Under Inappropriate Professional Behavior

Dangerous doctors slipping through the cracks

It took the discovery of guns and grenades to suspend the license of a psychiatrist who some say should have come under scrutiny years earlier

By Megan Twohey, Tribune reporter 8:50 p.m. CST, February 24, 2011 posted on http://darkestcloset.blogspot.com/

One night a Crestwood police sergeant doing a routine building check noticed an open door to the office of psychiatrist Joel Carroll. Stepping inside the cluttered office, he discovered roaming cats, a Colt AR-15 assault rifle and other guns, ammunition, military-grade smoke grenades, sex toys, and pornography.

"Well, for the lack of better terminology, we considered it a pigsty," Sgt. Thomas Kaniewski testified about his April 2009 discovery. "It looked in complete disarray. We couldn't believe that someone could actually conduct business in an office like that because of the conditions it was in."

When state regulators determined that Carroll had engaged in sexual misconduct and committed other violations of the state Medical Practice Act, they suspended his license, proclaiming him "a danger to his patients," according to state records.

But the psychiatrist's practice could have been shut down years earlier, after the Illinois Department of Corrections in 2007 found that Carroll — as a state contractor — committed inappropriate conduct with a female inmate and barred him from working in a prison, a Tribune investigation showed.

Critics say the case raises questions about a crucial part of the medical disciplinary system.

State agencies, county prosecutors, insurance companies, and health care employers and associations are mandatory reporters — they're required to report potentially dangerous and unprofessional doctors to medical regulators, who can bar the doctors from practicing and keep patients out of harm's way.

But the mandatory reporters sound few alarms, and when they do, regulators rarely take action, the Tribune found. There were 348 mandatory reports filed with the state in 2009. That's out of nearly 46,000 physicians statewide. In only one case did the Illinois Department of Financial and Professional Regulation respond by suspending the physician's license, records show.

Sue Hofer, a department spokeswoman, said it can take longer than a year to discipline a doctor following a mandatory report. She said regulators frequently learn of a dangerous doctor from members of the public before being told about the doctor from a mandatory reporter. If they are already investigating, she said, the regulators don't make a separate record of the notification.

But in the case of Carroll, the corrections department provided no notification that the psychiatrist had breached security during a visit to the inmate and allegedly made a sexual advance toward her, even though state agencies must report any potential violation of the Medical Practice Act. Carroll's actions might have amounted to "dishonorable, unethical or unprofessional conduct" — a violation under the act that can lead to suspension — but regulators were robbed of the opportunity to seek disciplinary action, said John Goldberg, a former medical prosecutor.

"The Department of Corrections should have reported, but these agencies hardly ever do," Goldberg said. "If they had, the regulators could have opened an investigation that at the very least asked: What's the explanation for your actions against this inmate? What else is this doctor doing?"

Regulators also were not contacted at the time by Wexford Health Sources, the contracting agency that fired him after his administrative lockout from the prison system. Health care employers must report terminating or restricting a doctor's privileges based on actions that may directly threaten patient care. Elaine Gedman, a spokeswoman for the Pittsburgh-based company, said that in 2007 the "Department of Corrections did not necessarily disclose their rationale for revoking an employee's clearance."

"When we look at this, we realize there are places where dangerous doctors get caught, where they're identified, but no one reports it, or the state doesn't take action," said Gary Schoener, a Minneapolis psychologist who has consulted on thousands of medical misconduct cases across the country.

Sharyn Elman, a corrections spokeswoman, said prison officials believe they did not have to report Carroll to regulators because they could confirm only that he breached security during a visit to the female inmate, not that he engaged in sexual misconduct as alleged.

But after police stumbled on the office, regulators received documentation from the Department of Corrections indicating "the doctor had told that inmate that he would take her to Mexico, and hugged her and kissed her," a medical investigator said during a 2009 disciplinary hearing.

Carroll, who could not be reached for comment, said in the hearing that the inmate made a pass at him, not vice versa.

The psychiatrist maintained his practice while he worked in the prison system from September 2006 to February 2007 and during several months in 2009 while he worked at medical centers for veterans in Danville and Marion.

His personal appearance was concerning to patients and other observers, as was his office, according to testimony.

One former patient said the psychiatrist went shoeless with holes in his socks. A pharmacist questioned whether he was really a doctor.

"He looked messy, unkempt," the pharmacist testified in a disciplinary hearing. "I was surprised at his appearance. He did not look, to me, like any physician I had ever met before. … He was wearing a T-shirt. It did not appear to be clean. It was very wrinkled. He was unshaven."

Carroll's former secretary said the presence of pornography and guns in the office was disturbing.

"The point is, putting myself aside, why does a doctor — a psychiatrist — have guns in the office with psychiatric patients?" she said during a hearing. "That's the problem."

When asked about the weapons in his office, Carroll said he collected them for fun and protection. He told authorities he had close to 100 guns stored in the walls of a Skokie home, state records show. Carroll had a firearms license.

The police never arrested Carroll. During the disciplinary hearing, Kaniewski said he did not know whether Carroll's assault rifle was a type that is illegal for him to own, only that he thought it was cause for concern. (Crestwood police Chief Theresa Neubauer did not respond to written questions or calls seeking comment.)

While law enforcement did not pursue charges against Carroll, state regulators determined that having these weapons at his office amounted to dishonorable, unethical or unprofessional conduct.

The former secretary, who first had been a patient of Carroll's, said she was surprised when he visited her behind bars and then offered her a job immediately after she finished serving time for a drug conviction.

Carroll gave her presigned prescriptions to use when he was out of the office, she said. The woman, a recovering drug addict who had no medical training and suffered from bipolar disease, would pen prescriptions for patients — a violation of drug laws, a Drug Enforcement Administration official testified.

"The medications would range from antidepressants all the way up to controlled substances such as Methadone," the woman explained during the hearing.

Carroll took the woman to New Mexico when he attended a conference and they shared a hotel room, according to the secretary's testimony. Carroll denied it, but she testified he walked around in his underwear and made an unwelcome sexual advance toward her.

When the secretary quit after the state launched its investigation, Carroll showed up at her home more than once, prompting her to call Chicago Ridge police, records show.

"Because after the investigation started, he went and he bought more guns and he just … I don't trust him today," she said in a hearing.

Carroll admitted he spent numerous nights at the home of a patient who suffered from anxiety and panic disorder, state records show. Regulators alleged he took nude pictures of her while she was asleep, threatened to have her committed, masturbated in front of her and attempted to climb through her bedroom window while she was in bed with her boyfriend — all of which he denied.

Another former patient who had turned to Carroll for treatment of severe anxiety said she was confused when he showed up unannounced at her family's Crestwood home. He allegedly tried to kiss her as he was leaving, which prompted her to cry to her mother.

The psychiatrist allegedly returned to the house more than 20 times, records show. The woman and her mother testified he would lay his body against the doorbell and throw rocks at her window.

"It upset me. I was crying. … I did call his telephone and asked him to please don't come to my house," the former patient said in a medical disciplinary hearing.

Carroll said he only threw rocks at the woman's window once. He denied he tried to kiss her.

When she realized the Department of Corrections and Wexford Health Services had taken action against Carroll in 2007 but had not informed regulators, she was outraged.

"This guy should have been out years ago," the woman said. "This should never have happened to any of us."

Withdrawal from the drugs wasn't the only hard part, she said. Her anxiety, already debilitating, worsened.

She is afraid to leave her home, she said, for fear that Carroll will be outside.

mtwohey@tribune.com